Mastering Competencies in Family Therapy

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Mastering Competencies in
          Family Therapy:
  A Practical Approach to Theories and
           Clinical Case Documentation


                                   CHAPTER 6

       Document it: Progress Notes

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Chapter 6: Mastering Competencies in Family Therapy

Progress Notes Leave a Trail....

       Primary way to show meeting
       "standard of care"
       Protection against
       lawsuits/complaints




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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
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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


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 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



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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


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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.
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