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Uniform Glossary of Terms

Administrative Manual

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Clinical documentation of therapy sessions

General guidelines
Clinical notes for outpatient and inpatient therapy sessions serve as documentation to:

  • Ensure that quality of care is adequate
  • Record the patient’s clinical status and progress
  • Offer documentation so that payment is made for services provided

Clinical notes do not need to be lengthy and should include:

  • Date and length of the therapy sessions
  • Treatment plan for the immediate future
  • Summary of the session’s therapeutic intervention
  • Content of the therapy session (e.g., note of the major themes discussed)
  • Patient's current clinical status as it relates to diagnosis and as evidenced by the mental status observations
  • Summary of the provider’s assessment of the patient's progress or lack of progress toward the treatment goals
  • Medications being prescribed by the provider, such as the name, dosage, instructions and any side effects that have occurred.
    • The record should document that noted positive benefits outweigh noted side effects.

Group, Conjoint and Family Therapy
Clinical notes are required for each group, conjoint or family therapy session and should include:

  • Number of participants
  • Date and length of the therapy session
  • Content of the therapy session (e.g., major themes discussed)
  • Relationship of the participants to the patient, if it is conjoint or family therapy
  • Nature and degree of the patient's participation and response to the therapy session
  • Statement summarizing the therapeutic intervention attempted during the therapy session
  • Statement summarizing how the session has influenced the patient (or relevant significant others) as compared with the treatment goals

The record should also include documentation that each therapy session was an active, directed process and that the therapist regularly took stock of specific important treatment issues.

Inpatient Psychotherapy
Clinical notes for inpatient psychotherapy should contain all of the elements noted previously in order to adequately document that individual therapy was provided.

Therapeutic progress notes should occasionally include reference to progress regarding the therapeutic plan and the discharge plan, both of which should have been established and documented during the early part of the hospitalization.

These documentation requirements should serve to assist in the maintenance of an adequate level of quality of care as well as to help ensure that payment is made only for services rendered.

 

Revised March 1, 2010