Hi, this is Dr.

Diane Gay Harden, Welcome to my lecture on progress notes that

goes with my textbook mastering competencies and Family Therapy, the second
edition. In his lecture, I'm going to talk about how to write progress notes. And
you will find that these are one of the most common clinical forms of
documentation. And as you work in the field as a therapist or a counselor, you will
be completing several of these each day. So hopefully this lecture will get you
started. So progress notes or the document that you complete everyday after seeing
a client and a typical session. And and what happens in this document is you
basically it is the official record of what happened and what you did. So the one
hand the most basic reason for doing progress notes is for you to keep a record of
what you're doing from week to week to kind of track your sessions and care. So
that's the most basic purpose of a progress note. And in a larger sense, there's a,
there's an ethical and professional standard for maintaining these because it is
the only real documentation we have. It's a field where we sit in a room and we
talk to people. And then, you know, it's based on our work, but we did. And so we
use these progress notes to document what happened. And so these are very important
for third-party payers to keep track of what happens if there's ever questions
about what happened in session. And similarly, progress notes can be helpful in
protecting against lawsuits or complaints on because a document what we did. And so
these are generally considered protection or can't be protection and those types of
situations. And so generally, it's important to also notice under the new HIPAA
regulations like his hip isn't that knew 2004, I believe. But in that way back then
in 2004, there was a distinction has been made between progress notes and
psychotherapy notes. So progress nodes are the official medical record that can be
shared with other medical professionals. And it generally has a little more limited
scope in the sense that there's certain things that are supposed to go into a HIPAA
base progress down and we're going to go into that in just a minute. But it
basically is documenting the symptoms of client had and what you did about that.
And that's the main thing that a progress notes does. And as the name indicates,
you're tracking progress. On the other hand, psychotherapy nodes are separate and
from progress notes. And these are more for the, the clinician in terms of thinking
through case, conceptualizing, and putting their thoughts onto paper. Psychotherapy
notes are kept in a distinct and separate place and file can be kept separate from
the official medical records. So for example, when you don't have the physician is
requisitioning or requesting a copy of of of records, you would generally just send
the progress notes were psychotherapy notes are often have basically more
subjective impressions that the clinician has is these are protected a bit more.
And it's really more on rare circumstances where the psychotherapy notes
specifically would be subpoenaed and normally that would be in some kind of legal
case where there's been a complaint against the clinician. So psychotherapy knows
if you're going and you do not need to maintain psychotherapy knows they are
optional. If you do maintain them, they should be kept in a separate file on
physical separate physical or digital files separate from the progress notes, which
are the official record. For the most part, anything we put in psychotherapy note,
so the rest and the remainder of this lecture is on, it's on how to write progress
notes because you can put what you want in psychotherapy notes generally. I mean,
obviously it should be professional. But they are really for the clinician. We're
progress notes have become more standardized with the hip, HIPAA legislation of
privacy legislation in 2004. So when you're writing a progress doubts, you really
want to do two things you want to or balanced to different priorities. You want to
maximize client privacy. Knowing that these are official medical records that can
be subpoenaed and share with other medical providers. While at the same time, you
want to document competent treatment and that you're conforming to professional
standards of care. So you need to put enough in there to document competent care
for there to be a medical record of what happened. The specifically related to
treating the diagnosed or condition or the focus of treatment, while at the same
time maximizing client privacy. So these progressions are going to contain detailed
information about the frequency and duration of symptoms. That's considered
standard medical record information. You also want to include very clearly the
interventions that you use to treat symptoms that so you're going to document your
competency. Decline came in with these problems. And this is the frequency and
duration of the problems. And then this is what I did about interventions. And then
also if there was any type of crisis situation such as suicide or self-harm. Child
abuse. Progress notes are also used to document how you stabilize crisis. So does
also a particular area of focus that needs careful documentation in your progress
notes. The good thing about progress notes is that there are now common ingredients
to your average progress note. And that's really been through the HIPAA legislation
that kind of outlined what should be in a progress note, which is something we
didn't have this consistently before these regulations. So the first thing I
generally is that you will have a client case number. And in most cases you want to
not use a name but use a number because this protects client privacy so that their
name isn't needlessly documented someplace. And as with all medical records, there
should be a date, time, the length of session. And this is especially if you're
doing third party billing are important to have this clearly documented. And then
obviously you also want to document who attended the session because that's also
very important information. At the typically also there needs to be the clinicians
original professional signature with your title. And generally, if you are in
training, working under someone else's license in many situations, you'll also have
your supervisor signature there. And then one of the most important things to a
document is client progress. So you'll document the symptoms, the frequency,
duration of symptoms, and how bad are they this week, where did they happen is
better or worse than last week? That these are the types of things you would
document. And then also the interventions again, what you did for that typically,
there's also plans for future sent sessions. What do you plan to do next week based
on this week? And again, if there were any crisis issues, you will want to go into
some detail documenting what you did to stabilize it. And then once you've
identified a crisis such as self-harm, week to week, checking in about whether or
not there was futures self-harm as therapy progresses. The nice thing about
progress notes is that once you understand the basic ingredients, no matter where
you go, where you work or what agency you're at. If you look closely below the
different formats, you will find they all pretty much nowadays. After HIPPA have
very similar ingredients are just arrange differently. So two of the more common
format you might find are DAP notes and soap notes. And you will see that even
though these look like very different acronyms, that the information in them is
very similar. So the Datanode stands for data assessment and plan. And so the data
is generally, and again, different agencies and clinicians can put different things
here. But generally the data is going to be some content about what happened to the
client since the last session. In the assessment, you'll generally put the
duration, frequency of the symptoms, what the things are progressing or if there's
been backsliding for whatever reason. And then the plan is what do you plan to do
next week and or robot revision to the treatment plan so that your basic DAP note.
So know that you're going to see is very similar and some nodes are actually
frequently used in the medical community. And so you'll see a lot of different
mental health agencies also using them, especially if they're connected with
medical communities. So notes, generalist Danforth, objective observations,
objective observations, assessment and plan. So that assessment and plan are still
there. And so I have seen actually that soap notes can be used and that slightly
differently in these acronyms, even though they look really clear cut, can be used
differently by different agencies. So in general, objective observations are going
to be talking about either the clinicians are the client's objective report about
what happened over the week. The objective observations are going to be focusing on
more measurable reports or MIT, objective observations by the clinician. Again, the
assessment will be talking and focusing on the progress made, whether we're going
forward or backwards and the duration and frequency of symptoms. And then again,
the plan will be, what do you plan to do next week and or what you plan to do with
the treatment plan. So these are two common formats and I will let you know, do not
be surprised if in a different agencies that different people interpret what goes
in these categories slightly differently. So in my textbook, I have put together a
progress note template that you can use that I call the all-purpose HIPAA progress
note that includes all the important HIPAA ingredients. It just spelled out a bit
more. And so you're going to see at the top of this, there is the initial
information that has the client number, the date, time, length of the session, who
was present. And it
will include the CPT billing codes. And you'll note that in 2013, these codes
change per mental health practitioners. So in the second edition you will see the
new 2013 Coase. And if you have an older edition of Mastering Competencies, you
will have the, the other codes that were in place for at least 20 years or more. So
that's the initial information that you will see. And then you need to fill in the
symptom progress. And so that is the duration and frequency and severity of the
symptoms as well as the intervention. So what did you do about it? And then the
client response is typically are often also included in progress notes. And so that
is how did the client respond to the interventions? Were they receptive, wizard,
some hesitancy or resistance. And so there's a place for you to document that there
than you include your plan and how you handled any crisis issues. And then at the
bottom, there's a place, especially for trainees, where you can put in whether you
consulted with other professionals and supervision and and or whether you made any
type of collateral contacts, such as calling calling family members or social
workers. And then finally, there's a place for professional signatures, which would
be your signature if your intern or trainee. And then in some agencies they would
also have you have your supervisor sign off on those. So in the next several
slides, what I want to do is break down this form and kind of walk you through how
to fill it out in a little more detail. So starting with the beginning initial
information on the progress note, like I've mentioned before, you want to try they
generally use a client number instead of a name. And this is particularly important
if for any reason you're at a place where your notes or sometimes separate from the
physical file and your notes can get misplaced. I always think it's a great thing
if you can actually have the note fall out of the file and land on the floor and
you can look at and not know exactly where it goes. The only person who would know
who that's about is the person who actually wrote the progress note because it's
confidential enough that it's, you know, if it slips out, there's a little more
protection for the client. You do it that way. I know not all agencies will will do
it that way. It's good for protecting client information. Then you of course, that
the date, the time, and the length of session and that length of session should
match up with your billing code. And then you end up with who was present. And I
like to use the abbreviations AF for adult female, AN adult male cf, and then an
age for child female, and then cm and a number for child male. And the reason I do
this, even when you're working with a family, really makes it much faster and
easier and I don't know any other way to really document without using name so much
with the family. So when you're working with a couple of our family, it really is
helpful. But also even when you're working with an individual, it is quite helpful.
It's very fast to note it. And you can, even if you're working, let's say for
example, with the adult female, you're working with the woman, but she's referring
to her kids, her husband, or a lover. It's much better to be using abbreviations
like this than to actually putting people's names. And sometimes it becomes even
awkward to write out, you know, husband, lover if they're having an affair. So
yeah, it's probably best to not even use that term. So I really find it using these
abbreviations can be very, very helpful in terms of protecting client
confidentiality in multiple ways. As well as if you do have supervisors reading.
It's, it's very quick and easy for third person to read this and understand who the
players are, what the issues might be, because you can have the ages and everything
like that. If a woman talking about an eight year old kid or 16, or even a 22-year-
old kid. It just very quick notation that makes it easy. And so, So that said that
there are different agencies that have the convention of using CL for client and
that's also an option. So let's see. In addition, we have here the CPT billing
codes, and this is the Procedural Terminology codes are set forth by the American
Medical Association in 2013. They actually change all these for mental health. So
what do you have? The most common used weren't commonly used ones are 90, 79 line,
which is a diagnostic interview and it's generally used for the first session. Then
you have 90834 and this is typically used for 4550 minute session with the client
and or family member may be present. And so this is your typical session
psychotherapy session. And there is also a nano 90846, which is 45 minutes a family
psychotherapy when the focuses is for the family. And in the textbook I list out
all the other commonly used codes for mental health practitioners. And these are
good to use when you're working generally with insurance companies, they will use
these codes. If you're working for something like a large county mental health
agency, they may have their own internal codes that they're using. Otherwise for
medical purposes, most people would use the codes put forth by the American Medical
Association. The next thing you're going to document, and for many people, this is
one of the main things. A document in your weekly progress notes is the symptom
progress. And so for this, you're going to be focusing on duration, frequency, and
severity of the symptoms. And especially when using the DSM BY that has a lot of
dimensional assessment indicating the severity from week to week is particularly
important. So indicating whether it's mild, moderate, or severe is a particular
interest. So some examples of how you would do this. The first thing to note is
that generally the convention is you're going to say client reported or clients
dated for virtually everything in a progress note. And because obviously we're most
Ali information unless you're observing it, is based on client report and it's just
important to to to indicate that you are aware that this is something that the
client told you versus something that you observed. So examples of how this might
look is the client reported mild depression or mild yeah. Depressed mood for most
days in a week or five out of seven days. So here we've got the severity and the
frequency of the depressive mood symptom. So again, we have here climb reports when
panic attack over the past week with moderate severity. So CLI reports decrease
conflict with parents to arguments in the past week. So here, these are some of the
different ways that you can document progress. And it kind of depends on the
symptom, whether you're putting in how much duration or frequency or severity. But
again, you want to get as for most for most third-party payers in the typical
convention is increasingly 1-sum, something kind of measurable. Sometimes that's
hard I know and mental health. But as much as you can define measurable symptoms
and try to indicate that as well as their severity from week to week in whether
things got better or worse. So once you've documented symptoms that the client has,
to document your competency, you need to indicate what you did, what interventions
you used, and how what you did to help the client with these particular symptoms.
So and when in this section I really encourage you to go through and find very
specific language. This is where you can document your, your theory and your, your
clinical case conceptualization comes through. And so this is real important to how
to think about how you language. This is saying something like You discussed work
stress or you've talked about client fears. I mean, that's all very nice. And we
expect that you did that. It doesn't actually document that you did something that
is based on the professional standards of the field. Because basically a bartender
or a hairdresser can talk about work stress or fears. So you'd want to distinguish
herself as a rendering some kind of professional care. And so this is really where
you document your competency here. So, and so again, it's very simple. You just
need to cite some of the techniques generally that are listed in the various
sections of the book. And that's probably the easiest way to go about putting
writing your intervention section. So some examples can be using solution focused
scaling to identify steps to reduce depression over the next week. So that's pretty
clear that you rendered some kind of known professional intervention there. You can
also do something like using enactments to practice alternative to conflict. These
are very short, but concise, and they refer to professional known interventions
that are well-respected. And so it does appear as of, you know, you did something
professional. And so you're again, you're documenting your competence, particularly
in the intervention section. Now this next section, client response may not be
included in all progress nodes at all agencies. But increasingly you will see this
in most. Progress notes in recent years. And basically, client response allows the
clinician to document how the client responded to the session and to the
interventions, or to just kinda note on what was going on. And so this is helpful
in particular to note if there's some kind of tension between the client and the
clinician. But it also can be very useful. Even you as a clinician, as you're
sitting down and just thinking about what did my client financially useful, seemed
least seemed on the outside. So rarely do they verbalized. That's like that was the
best reframe I've heard nears there knowing I'll say something to that effect. But
generally you get a sense of what was useful and what wasn't. And I have found that
since I've started documenting this on a regular basis, that I just pay a little
more attention to what went well and what
didn't. So even if you don't need to document this, because you're going to have
an unhappy client down the road, which I think is how it ended up as a document. I
have personally found that it helps me just tune in a little bit more. This
particular client finds helpful. Cuz some examples of things that you can write in
this in this space is called something like client receptors. The re-frame related
to work issues less receptors, the reframe on the patterns of the relationship. You
can plan actively engage an enactment, optimistic that they could do this at home.
Something like client expressed enthusiasm about mindfulness. So so you can use
this to just kinda document both for the official record but also for yourself to
notice what's working and what's not working. Kind of fine tuning what you do in
the next session based on their response in this session. So in this next part of
the note, you're going to talk about the plan. And this generally refers to the
plan for the next session, but it can also refer to more long-term plans and goals
within the treatment plan. But for, in most cases on your average proud progress
note you're just going to put down what you plan to do for the next session or two
to some examples could be that you will want to bring in like the parents for the
next section, our partner. And you can also follow up on a journaling or other
homework assignment. Uh-huh. If there has been any crisis issue, it's nice to note
that you plan to, in the next session, I'll continue to assess for self-harm or
suicidal ideation or whatever that might be. So this could actually be often the
most practical part for the clinician themselves through yeah. Next time The right
before the client comes, you can, you know, look over this and remind yourself what
you were planning to do with this session last week. So a lot of people use this
part that way. And also it is creates continuity of care if ever there different
clinicians and bulb. So this can often be the most useful part for you. In the next
section on the progress note, you will see that there's a place for crisis issues
to be addressed. And this, if there are crisis issues is generally the most
important part to document. Well. You're protecting yourself on liability issues
and you're also helping to document for the client what happened in the crisis
situation, how it was handled. And oftentimes, especially if you're an agency with
more than one clinician that might be looking at these notes or if there is a
crisis down the road after you leave with the same client. This is the most
important part to have documented well, both for your clients welfare as well as in
terms of legal liability issues. So what you want to document or any type of crisis
issues that arise in session. And so this is obviously things like child abuse,
elder abuse, dependent adult abuse, suicidal ideation, homicidal ideation, reports
of domestic violence. This can also include eating disorders, substance abuse,
obviously in the type of self-harm falls into this category. So there are quite a
number of different types of crisis issues that can be important to address and
even something like distributed announcing that there might be a divorce or
something like that back and also be considered a type of crisis issue in at least
a reason to be assessing for other potential crisis issues. So, so think broadly
when you think of crisis issues, not just the major child abuse or elder abuse and
suicide homicide. So when it comes time to documenting crisis issues, this is the
one time where your notes are going to be a little more detailed and a little more
specific. It helps often to use direct quotes from the client. For example, when
you are documenting I plan who has suicidal ideation? You're going to definitely
want to cover, you know, is it a passive suicidal ideation like I'd rather be dead
versus a more active ideation. I want to kill myself. Two very different
statements, although they sound somewhere. And so do they have a plan? Do they have
mean do they intend to do it? All those types of details need to be clearly
documented. And also if you're developing a safety plan and or, you know, when you
ask about reasons for living, those sorts of things are very helpful to put in
quotes. You know, I often have a lot of clients who will say something like you
now, I sometimes I wish I were dead, but of course I could never do it because of
my children. And so things like that are good to put in quotes. And what you want
to have. Ultimately when you're done with this section, is that you're going to
document all the concerns that were actually there and all of the mitigating
factors or other things and so that any reasonable person who reads through your
progress notes, who understands legal responsibilities of coalitions in your state,
would think and arrive at the same decision you made in terms of the action that
you take to keep your client safe. So you want to have enough information there if
you end up calling the client, infer suicide assessment and contacting the sheriffs
to do a formal assessment or having them taken to a psych hospital with your state
allows that. Then you need to have that clearly documented at any reasonable person
in your state would have taken the same type of action. And or similarly, if you
assess and determine that you don't, it doesn't meet the threshold for when you
need to take action in your particular state, then that needs to be clearly
documented. So any other clinician in the state reading through this would come to
a similar decision about what to do with that client and what's going on. So that's
the real GO goal here to make sure that you're documenting all of the reasons and
evidence. And that's where the having direct quotes can be particularly helpful.
And then you can also document everything you did to keep the client safe. So
whether you made a phone call, child protective services, whether you've developed
the safety plan, what are the basic steps, the safety plan, whether no harm
contract was signed, all those sorts of things. So this is very important. So on
the next slide here I'll look at some ways that you can document this, give you
some examples. So here you can see on the first example shows how you might in the
progress note itself documented that there were suspected child abuse in the
family. And you have to report the basic summary that the child was hit with a belt
and more than one occasion. There was a child abuse report made and the time and
who took it. And in this case here you can see full report, place and file. So
somewhere in this client's file, we should also find the full child abuse report
that would have more of the details. In this next example, we have a client who's
reported a passive suicidal ideation. I wish I were dead, but quickly denied plan
or intent. I would never do it because of my kid. So those quotes there help us
understand, you know, what was said where the client was does show that there was a
safety plan with renames to call whenever emergency contact for the therapist. So
here you can see how that was handled. And the next, what do we have reported
cutting twice a week, developed a safety plan in which a client agreed to scaling
for safety, to develop alternative action. When they hit a seven on the scale. And
the client readily agreed the plan. So that kind of shows that same D And that was
kind of client responds to the intervention is actually put right there. So you
have a sense of what went on. In this next one, you can see Client a nice cutting
this week, no new cuts and was evident. So again, here, this is what you're putting
in the safety crisis issue section. And then following week, you can also put this
under symptoms, I guess as long as it's somewhere, the progress note. But there
again, once you've assessed a crisis issue, should appear at least for subsequent
weeks for some time to show that you have assessed and that there was no evidence
of there being a problem, whether it's suicidal ideation or cutting or homicidal
ideation, those sorts of things. Usually with child abuse here we're having more
formal intervention, but you should still be assessing no evidence. Further abuses
should be regularly in your file either under the crisis section here or you in
some cases, you can also put it up at the top if you're perhaps documenting
depressed mood. So you could say no depressed mood or suicidal ideation. You can
talk to your supervisor where you want to put it, but I would say to progress than
it should have it in one place or the other. So finally, the last thing you might
want to document and maybe not an all work contexts where you documents up. Such
things are all elements of this. But if you are getting supervision, you can or
some form of consultation, you can document those recommendations or information
that you got from your supervisor. Similarly, if you contact me collateral
contacts, so that's calling valid numbers were non-treatment social workers,
physicians, psychiatrists, schoolteachers, other school personnel. So if you're
calling anyone in relationship to the case, you should be documenting that in your
files. And often it's called collateral contact. And it's useful to also know
whether or not you have a release of information that's there to help remind you
that you should. But so document in contact with other professionals or family
members. And then finally, there should be a signature. And generally what is
expected is it is an original signature and original date. I generally you include
your license status. And in some situations, if you're being supervisor's
supervisor should also be signing the progress note. But initials are not usually
acceptable on progress notes as a way of signing off. So you duty that original
signature. So that's basically
in a nutshell. What what's on a progress note or inner progress. Now, finally, I
just want to end with a few real practical suggestions and guidelines about doing
writing progress notes. The first is, and this may sound simplistic at first, but
it is Is writing your notes on a daily basis and generally, obviously immediately
after the session is best. But to really make it a practice that if you are seeing
clients that before you leave the building or whatever worksite you're at, that you
always do those progress notes before you leave. And that's clearly considered best
practice and it's generally is expected. And if you ever can't do that for whatever
reason and there will be a couple a handful of days may be in your career where
that will happen and when it has happened to me for whatever, usually there's
another crisis and I'm trying to attend to if some form. It is amazing how hard it
is to recall what happened yesterday and session. And you really do not recall it
with the same accuracy and clarity. Now if you only are seeing two or three
sessions a week, maybe in the beginning, you think you can get away with it or
maybe it's easier to do. But certainly once you end up S, after you have a full
regular, a load of clients, that becomes nearly impossible to do. So it's very
important that you make it a practice to always be doing this progress notes
following on the same day that you see those clients. And that is is just I don't
know how to emphasize how important enough that is. And I hear people talk about or
they don't always do that, are they? I'm about, are we doing it in the field? It's
still important to make it happen and to organize your professional lives so that
on a very regular basis, those are done every single day. And if for any reason
you're at a work site, that doesn't make that makes it very difficult for that to
happen. You really need to be having a conversation with your employer or your
supervisor because it really is an ethical issue that those should be done each day
and if for any reason they're not, it should be documented when they actually were
done so that it's clear when we see a date where the notes done that's after the
date of the actual session. That's also assign that these notes may not actually be
all that accurate. And that is how they would be interpreted in a legal setting
should end up there. So it's also important to know that as you probably do and you
can't say it enough that all progress nodes belong locked file when not in use. And
so that's very important. And I want to add to that an anything with plan
information should be locked when not in use. And so that includes, you know,
little notes with a client phone numbers or even sticky notes with client phone
numbers. Anything with client information should be locked up when not in use. And
in this digital age, that means password protecting, at least with one level of
password protection. And so if you call clients at all from your phone, if you use
your computer at all, you should be is peaking with your supervisor or employer
about standards for password protecting, you know, at multiple levels, usually to
ensure client confidentiality when you're using digital tech, digital devices. It's
become much more complex in some ways with the advent of iPhones and email to
really protect client confidentiality. So it's an art that we will. I think it's a
real challenge to keep everything confidential as digital technology kind of
explodes and what we can do and where our emails can end up. It's even more
important nowadays to really focus on client confidentiality. In general. You keep
client records for 70 years past the age of majority. That means pass the age of 18
is a general guidance for how long to keep these records. And so that's an
important thing to keep in mind. And for someone who's been in private, private,
private practice long enough to worry about these things. It's really nice if when
you close not the files, you can put what's the destroy date on it so that you can
organize them that way as you archive them over the years. Just, just a little note
to me. But under your cat for years down the road. So and that is it. I so
hopefully you've been and feel a little bit more comfortable and confident in terms
of writing progress notes and have a sense of where to go and what to do with
these. And I wish you the best and I know that should you stay in this field for
any length of time, you will be using what you've learned in this lecture for years
to come. Thanks so much.