Show Notes

Kayla: Welcome back, everyone to The Designer Practice Podcast. I’m your host, Kayla Das. Something that many of us struggle with is writing case notes. What to write? How much to write? And what important pieces might be missing?

Beth Rontal, Licensed Clinical Social Worker, Case Note Documentation Specialist, and owner of Documentation Wizard is here with us today to share with us the 5 most common case documentation mistakes, and how we can fix them so that our case notes are in tip-top shape.

Hi Beth. Welcome to the Designer Practice Podcast. It’s great to have you here today.

Beth: Thank you, Kayla. I’m really happy to be here. I’m one of these wonky therapists who just enjoy the results of the documentation and I really enjoy teaching it to other therapists so that they can protect themselves and protect their clients.

Kayla: When we think of case notes, they’re essential to clinical practice, but they’re also one of the things that cause therapists headaches and they trip them up. Whether it’s unclear direction about what to write or how much to write, or fear of writing the wrong thing in their case notes. Many private practitioners struggle with it. But you’re here to demystify case writing for us by sharing these five most common documentation mistakes so we don’t make them.

And from my experience, I didn’t have a special course about how to write effective case notes. There’s limited guidance when it comes to ethical standards or standards of practice, at least here in Canada regarding that. And there’s very few trainings like yours out there to provide guidance and support when it comes to learning the basics. So, when it comes to case note documentation, why is there such a divide with what therapists are expected to know and what we’re taught?

The Expectation-Learning Divide 

Beth: So, you actually touched on it a moment ago. You weren’t taught. This is not a skill that’s taught in graduate school. It’s really not a skill that’s taught in our internships, and it’s generally not taught in our jobs because our supervisors didn’t learn it in graduate school or in their internships. So, they’re just teaching us the best that they know and it may not be that good. And I am not disparaging our supervisors. I’ve had wonderful supervisors when I was a student, but they didn’t know. In fact, in my internships, I never did any documentation. It was quite remarkable. So, I just want to say there’s no shame in not knowing. You can’t know what you don’t know.

Kayla: Before we dive in today, please introduce yourself, where you’re located, and tell us a little bit about what you do, who you work with, and your specialty.

Beth: Thank you. I’m an LICSW. I live and work in Boston, Massachusetts, and I’ve been a therapist for over 20 years. But being a therapist was not my first gig. I was actually a costume designer and I worked in the theater for almost 20 years. And then I kind of burnt out in that profession and thought, “Hmm, what do I know better than anything else, besides costume design?” And I went, “Well, I’ve been in therapy for a long time. I think I know therapy pretty well.” And I decided that I wanted to be a therapist. I never, ever thought that I would become the Documentation Wizard. I thought that all I wanted to really do was be a really good trauma therapist and what does documentation have to do with that?

And I didn’t learn it in graduate school and I didn’t learn it in my internships and, I didn’t learn it in my job until I became a supervisor. So, I’ve worked in hospitals and clinics. I interned in an EAP. I was a dual diagnosis counsellor. I worked in residential. And I’ve run tons of groups and I’ve done outreach therapy, so where I’ve gone into people’s homes. So, I’ve had a pretty wide range of experience.

And not only did I not learn documentation in school, but I didn’t learn it on any of these jobs until I became a clinical supervisor. And I supervised over 50 clinicians in 11 years. And one of my responsibilities was to help develop the clinic’s first digital documentation system and teach it to my supervisees.

This system saved the clinic from going out of business because documentation could be done faster and it could be done accurately. And it helped my supervisees be clear about what and how much to write in a way that helped them be better therapists. Because you know what? If you have to document, it might as well be a contribution to your craft, right?

Kayla: Agree.

Beth: I call it self-supervision. We should think about what we’re doing in a way that allows us to think about what happened in the session and why it happened and what we might want to do in our coming sessions.

Kayla: Hearing your journey becoming a therapist, becoming a documentation specialist and it’s very aspirational.

Beth: Hmm. Thank you.

Why Case Note Documentation is Important

Kayla: When it comes to private practices, why is case documentation important?

Beth: Well, the first one is what I just said because we get to review what we did in a very systematic way. When we’re in the middle of a session, we’re just in the flow of the session, right? We’re using our skill, we’re using our intuition, and we’re with the client, and we’re doing what we know to do in the moment.

Documentation gives us an opportunity to reflect on that, so that is for me, one of the main things that I value about good documentation. And in order to do that, I must say you need to have a good template to walk you through it to make you think in the way that, that I think about documentation.

The other reason, though, is to fulfill professional ethics, whether we’re in the US or in Canada, we have professional ethics and our codes of ethics state what those professional ethics are in the realm of documentation. And we need to fulfill them because if there’s a board complaint and we haven’t fulfilled them we can get into trouble because every board complaint very quickly becomes about one’s notes because the board wants to see, what did you do? And what you did is supposed to be in your notes.

The other reason documentation is so important is because we need to learn how to document enough, but not so much that we reveal too much confidential information. So, we need to do it in a way that protects our clients and we need to do it, as I said before, as a way to protect ourselves from legal issues, from board complaints, and for Americans, we need to do it in order to protect ourselves from audits. And that’s a really big one for those therapists in the US who accept insurance.

Kayla: That makes complete sense. Let’s dive into the 5 most common documentation mistakes. So, what are those? And I know there might be a difference between say, US and Canadian and we’ll talk about that a little bit, but what are those 5 most common case note documentation mistakes.

Documenting to Medical Necessity Standards

Beth: So, I’m going to give a brief overview of medical necessity and I’m going to actually read some of the definition: Medical necessity are healthcare services that a healthcare provider exercising prudent clinical judgment would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness disease, or its symptoms that are in accordance with generally accepted standards of medical practice and are clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury, or disease. (National Academies Press, 2012)

That is a very broad overview, and there’s actually a lot more to that definition, but I’m not going to bore everybody by reading the whole thing. It lays out some basic groundwork that you need to document the type of work you’re doing. You need to document how frequently you see the person. You need to document how severe the issue is. You need to say where you’re seeing the person and for how long you expect to see the person. So those are some of the administrative requirements that need to be fulfilled.

So, here’s how I conceptualize medical necessity:

Each session is an experiment. The hypothesis is the diagnosis. The diagnosis is supported by evidence.

So, what’s the evidence?

Evidence are behaviors that demonstrate the symptoms. And then there’s process, which is also part of the evidence.

Well, what is the process?

The process is identifying the goals. What are the interventions? Documenting the interventions. What are the objectives or what is the client going to do to achieve the goals? And then we have to document whether the process is showing progress or fostering progress or the lack of progress. Progress justifies and informs future treatment and medical necessity is the conclusion of that experiment.

So medical necessity kind of boils down to how you justify continued treatment. So continued treatment is medically necessary to address, reduce and stabilize symptoms to manage chronic symptoms, to improve functioning, to maintain gains, to prevent decompensation, and to prevent a higher level of care.

So, we have to have our hypothesis, which is the diagnosis. We have to have all our supporting evidence, and then we have our conclusion.

Kayla: That’s an amazing breakdown of case notes. In my head I’m just visualizing it. And I’m sure some of our listeners are as well. It’s a great way to look at case notes and it’s a great framework to go by.

So, in Canada there’s no formal requirement to document for medical necessity like there is in the US. So, I’m wondering if there are things that Canadians could learn for documenting to medical necessity standards?

Beth: Yeah, American Medical Necessity Standards provides a very clear process on what’s needed and why it’s needed. Or at least the way I interpret it, provides a very clear process for doing it because the definition itself does not show you how to operationalize it. That’s where I come in and a good note template comes in.

When you’re thinking about documentation in a way that’s really useful. You’re asking yourself the questions of: What happened? How was the client presenting? How did I respond to the client presenting? What interventions did I use? What were the results of those interventions? Is there any risk here for the client? And how do we document that if there is risk? Is it low? Is it high? Is it medium? If it’s a high risk, where is your risk assessment? What have you done to help protect the client? Is the client-oriented times four? What is the progress the client has made towards the goals that you outlined in your treatment plan that were discussed in your initial sessions that you wrote in your initial biopsychosocial assessment?

So, documenting to medical necessity helps tie everything together so that what you do at the beginning of therapy has a through line all the way through to discharge and if you have to go off your plan. Then you document that you’ve had to go off your plan and why? The structure is a really nice formulaic way of thinking about your intuition and skill and documenting it.

Documenting Session Start and Stop Times

Kayla: That makes complete sense. So, you touched on this earlier when we were talking about medical necessities and some of the requirements, but what is the second mistake that therapists make?

Beth: The second mistake that therapists make is to not write down the exact start and stop time of the session. Now in the US this is a requirement from the insurance companies because it’s how they verify which CPT code you said you used. In other words, did you provide a 90834, which is 36 to 52 minutes? Or did you provide a 90837, which is 53 minutes or above?

So, if you document the exact start and the exact stop time, the insurance companies have a verification that you provided exactly what you said you provided, and then they feel justified in paying you for the increased time that you’ve spent. But there’s another reason to document the exact start and stop time, and this applies across the board, and that is, you have a record of when the client was either in your office or on video with you, and should the client decide to file a board complaint and say they were with you at a certain time and complain about something that you did or didn’t do or something that happened on your property, like a slip and fall at a time that they weren’t there, that you have documented, you’re now protected.

Kayla: For Canadian listeners, I know you’ve mentioned a bunch of different numbers there, and obviously our insurance companies are very different. So, can you explain for Canadian listeners what those numbers mean?

Beth: Yes. So, in the US we use different codes to explain how long we sat with the client. So, if we were with a client for, as I said earlier, like 36 to 52 minutes, then we use one CPT code, which is 90834, and this goes on our billing form that we submit to the insurance companies and they pay us a certain rate for that CPT code.

If we submit for a 90837, they pay us a higher rate for that CPT code. So, it’s really an administrative requirement that we have to fulfill or we can’t possibly get paid because they don’t know what to pay us.

Use Cognitive Behavioural Therapy (CBT) Language in Case Note Writing

Kayla: I’ve learned this from you, that when we think of case note documentation, that it’s best to use CBT or cognitive behavioural therapy language when you are documenting. Can you tell us a little bit about this and why this is important?

Beth: Yeah, I sure can. The first thing I want to say though is you do not have to be a CBT expert or CBT certified in order to use the language.

CBT has become the language of documentation for two reasons. One is when therapists were able to accept insurance in the 70’s, they needed to be able to document to medical standards just like every other provider, and show change and progress. And how does change show up? Change shows up in behaviour, right? And everybody wants to know that behaviour is changing. The client sure wants to know. The therapist takes great pleasure in knowing. And the insurance company needs to know.

So, when I teach documentation, I don’t just say that you have to write down your diagnosis and then all the diagnostic criteria, because that’s kind of like writing a treatment plan for a diagnosis. You’re to be writing a treatment plan for the person you’re working with. And believe it or not, the insurance companies want that as well.

So how do you write a treatment plan for the person you’re working with? You do it by linking the diagnostic criteria with behaviour. So, if the person says, I’m really depressed. Then one of the questions I ask that person is, what does that depression make you do or not do? Because that’s a very behavioural question, right?

What do you do or what do you not do? And it’s also a therapeutic question because many of our clients come in without much ability to self-observe. So, we’re already asking them to observe their behaviour and they may struggle with that. So, then we pull up our diagnostic criteria for depression and we say, “A lot of people cry a lot when they’re depressed. Do you cry?” “Yeah.” How often? And does it last long? Does it come out of the blue? Does it feel like you’re just sad or does it feel like you’re bereft and hopeless? So, then you get to go into more of the details.

But some clients even have a problem with that. They have their ability to self-observe is not great. So, then I ask them to take a look from higher up and say, if your life were a movie and someone were seeing you as if you were in a movie, what would they see you do that made you look depressed? What would they see you do or not do that would show you were depressed? And that’s a useful question because it then puts the client in somebody else’s shoes. Which some people have a really hard time doing. So that in itself is therapeutic, which goes back to what I said earlier about how documentation can be a useful clinical tool.

Kayla: It’s interesting that you add CBT as an approach to help write case notes because even when it comes to marketing, when I help therapists identify their ideal client I have them identify through a CBT framework. A common activity that I have therapists complete is what I call a Private Practice Persona, where they write down common problems, situations, and needs that their clients are experiencing.

But one of the first steps is really identifying what are the emotions that your ideal client is experiencing? What are the thoughts that they’re experiencing? Their behaviors? Their symptoms? What causes them pain? Why are they seeking counselling? What was that pivotal moment that brought them to counselling from a behavioural or cognitive perspective. And once we know what those symptoms are or how they manifest internally or outwardly, we can reflect that back through our advertising copy. Whether it’s our website or Psychology Today profile, any type of marketing material because it hits home for our ideal clients. They understand their behaviours. They understand their emotions.

And I know I’m kind of digressing here, but I just wanted to show how powerful CBT can be and how its application can be used in many ways.

Beth: It’s a digression, but it fits beautifully because how you describe, to identify your ideal client is very similar to how you get information to write a treatment plan. You’re just asking a little bit more in depth. How often does it happen or what’s the severity? If you were to rate the severity of how bad it is out of 0 to 10, zero being not at all, and 10 being like emergency room, where would you rate it? Um,

Documenting behaviors is so useful. It gives us concrete ways to measure change. But you do not have to be a CBT therapist. I use a lot of internal family systems that is really far from CBT, but we’re still documenting change. We’re just talking about it in a different way.

And I want to remind people that cognitive distortions is a form of behaviour. The thinking process is a behavioural process, right? How we feel can show up in behaviours. What does that sadness make you do? I cry a lot. How often do you cry? A lot. Well, geez, I’m sorry to hear that. But what does a lot mean? Well, all the time. Well, what does all the time mean?

It can be difficult to get the specifics. And that’s when I go into, can you rate it? Is it mild? Is it medium? Is it severe? Is it on a 0 to 10? Or how often have you cried in the past two weeks? Or are there certain things that make you cry? Every question leads to another question, and I want to acknowledge that it can be difficult to get specifics. So, we do our best in getting specific.

Document Progress in Your Case Notes

Kayla: Perfect. So, when we were discussing topics for this podcast episode, you mentioned the importance of documenting progress in a specific way. Can you describe that?

Beth: Yeah. Progress is documented just the way everything else is documented, and that’s as a behaviour. First of all, a lot of therapists think that if they keep documenting no progress, that the insurance companies who do have some control over how much and how often we see clients, that the insurance companies will limit our ability to see our clients because they’ll say, “Well, this person’s obviously reached their highest level of functioning so you can’t see them every week.” When you know that you are keeping this client functioning by seeing them every week. That is an unfortunate fallout of the American system.

So, it’s really important to document the specifics of the behaviours just like documenting the behaviors in your treatment plan, what has changed? What is the client now able to do? It can be really tiny. A really small change. But it’s so useful and therapeutic to look for change. Because it is small. It does come in tiny increments. And it’s important for the client to know it and for the therapist to know it. So, if we don’t get discouraged.

How to Document Poor Self-Esteem in Case Notes

Kayla: So, I’ve read one of your blogs about avoiding the use of improve poor self-esteem in case note documentation when it comes to gold setting. Can you tell me why you don’t recommend using the term improve poor self-esteem in this way?

Beth: Yeah, because first of all, I just want to acknowledge that poor self-esteem is part of the diagnostic criteria in dysthymic disorder. So, it makes logical sense to use poor self-esteem when you’re documenting the problem, right? And as a goal, improve self-esteem.

However, self-esteem can look different for different people. So, what are the behaviours that show up as poor self-esteem? Now, for example, you could have one person who engages in very risky behaviour and that demonstrates poor self-esteem. But you could have another person who engages in risky behaviour, and that’s not poor self-esteem.

If you are documenting the behaviour, then it’s measurable and you can show improvement, or you can also show when somebody decompensates.

Kayla: So, if you’d like to read Beth’s article, How to Document Low Self-Esteem, you can check it out at kayladas.com/bethrontalblog.

That’s kayladas.com/bethrontalblog.

So, let’s recap. Can you share with us briefly what these 5 mistakes are again?

Beth: 1. Not documenting start and stop times.

2. Not documenting progress in behavioral terms,

3. Not using behavioral language

4. Not documenting to medical necessity

5. Not having a systematized way of writing your notes and your treatment plans, and frankly, all the other documentation that’s required.

Learn More about Case Note Documentation

Kayla: Perfect. So, you have an upcoming webinar happening. Can you please tell us a little bit about your webinar and what it’s about and how people can reach you?

Beth: I would love to. It’s called Misery or Mastery: Documenting Medical Necessity for Psychotherapists. It’s coming up on Friday, May 12th, 2023. It’s an all-day webinar from 10:00 AM to 6:00 PM Eastern Daylight Time.

And what I do is teach you documentation from intake to discharge, so you learn how to write a really good trauma-informed and diversity-informed diagnostic summary. You learn how to write a treatment plan that demonstrates or sets up the behaviours that need to change. You learn how to write a session note that reflects your treatment plan. You learn how to write a collateral contact note. In other words, if you’re speaking with the prescriber, or the PCP, or somebody else involved in the client’s treatment then you document that exchange as well. And I teach you how to do that. And then I teach people how to write a discharge summary so everything flows together from beginning to end.

And what I like to say is I teach therapists how to turn their clinical skill and intuition into a formula that supports medical necessity that passes audits if you’re American, that fulfills our professional standards of care because we all have them. How to do it in a way that protects client confidentiality and how to do it in a way that protects us as therapists and how to do it effectively and efficiently. So, it doesn’t take up so much time.

I provide context as well as content because we all learn better in when we understand the reasons for it. And I cover all the learning styles. So, there’s lecture, there’s lots of case examples, there’s a detailed PowerPoint, and two practice sessions and the ability to ask a lot of questions in the chat.

There are several bonuses, including 2 one-hour follow-up question and answer sessions that are scheduled several weeks afterwards to give the participants a chance to internalize what they have learned and then come back and ask very specific targeted questions.

And finally, I’m going to just say people tell me it is surprisingly engaging and actually interesting and clinically useful. If it can’t be engaging and clinically useful, ooh, who would want to do it?

Kayla: Yeah. It sounds like the complete case note toolkit.

Beth: That’s a great way to describe it.

Kayla: Yeah. So, if you are interested in checking out Beth’s webinar, you can head to kayladas.com/bethrontalwebinar.

That’s kayladas.com/bethrontalwebinar.

Or you can simply scroll down to the show notes and click on the link.

Conclusion

Thank you, Beth, for joining us today on the show and sharing these practical tips for effective case note documentation. It’s been so great having you here.

Beth: Thank you. I’ve really enjoyed it. It’s a pleasure.

Kayla: Thank you everyone for tuning in to today’s episode, and I hope you join me again soon on The Designer Practice Podcast.

Until next time.

Bye for now.

Credits & Disclaimers

Music by ItsWatR from Pixabay

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Reference

National Academies Press. 2012. Essential Health Benefits: Balancing Coverage and Cost. Appendix G: Medical Necessity. Retrieved from https://nap.nationalacademies.org/read/13234/chapter/19