


Mastering Competencies in Family Therapy: A Practical Approach to Theories and Clinical Case Documentation CHAPTER 6 Document it: Progress Notes 1 Chapter 6: Mastering Competencies in Family Therapy Progress Notes Leave a Trail.... Primary way to show meeting "standard of care" Protection against lawsuits/complaints 2 Chapter 6: Mastering Competencies in Family Therapy Two Types of Notes Progress Notes "Official" record shared with other medical professionals upon request Required for all clients Specific elements required Psychotherapy Notes Must be kept separate from progress notes (I.e., separate folder) Used by clinician to help think through and plan client progress Can be shared and/or subpoenaed under very limited circumstances Chapter 6: Mastering Competencies in Family Therapy Progress Notes Two Guiding Principles to counterbalance Maximize client privacy while simultaneously Documenting competent treatment that conforms to professional standards of care To Protect Client Privacy minimize Unnecessary personal details of client life To Document Competency include detailed information about Frequency and duration of symptoms Interventions used to treat symptoms Crisis management 4 Chapter 6: Mastering Competencies in Family Therapy Progress Note Ingredients HIPAA guidelines/Third-party payers common ingredients Client case number (no name/privacy) Date, time & length of session Who attended the session Provider's original, professional signature Clients progress Interventions and plans for future sessions Assessment for crisis issues 5 Chapter 6: Mastering Competencies in Family Therapy Common Progress Note Formats DAP Notes SOAP Notes Managed Medical format Care Format Contains Data Subjective Observations Assessment Objective Plan Observations Assessment Plan 6 Chapter 6: Mastering Competencies in Family Therapy The All-Purpose HIPAA Progress Note Session Basics Clinical Information Client# (never Symptoms and progress name) Interventions Date Client response to Time and length treatment of session Plan Persons present Crisis issues Consultation & CPT billing Supervision, codes Collateral Contacts Signature with license status 7 Chapter 6: Mastering Competencies in Family Therapy Completing a Progress Note Identification Client ID number (no names) Date, time and length of session Who attended the session AF, AM, CF#, CM# CPT code and type of session Or county mental health codes Chapter 6: Mastering Competencies in Family Therapy Completing a Progress Note Client progress including Improvement/worsening of symptoms Frequency and/or duration Ex. Client reports depressed mood 5 days this week; moderate; worse in morning; slightly less frequent than last week. Interventions used and client response USE THERAPEUTIC LANGUAGE Ex. Used solution-focused scaling to identify two tasks to improve mood in following week (exercise and coffee with friend). Client generated ideas and seemed hopeful about and committed to week's assignments.Download Link: