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:
