A Therapist's #1 Secret Productivity Killer

I talk with a lot of therapists who have trouble keeping up with notes. Yet, when we actually sit down to write notes together it only takes about five minutes to write one note (on average). 

Even if you see 20 clients a week, that's only an hour and 40 minutes every week to keep up with notes. If we assume a 40 hour work week, that still leaves more than 18 hours each week for all the extra administrative stuff you do (answering phone calls, marketing, billing, networking, etc.). This makes paperwork, and particularly notes, seem like a really small portion of the weekly workload, right? Especially when we consider how important your notes are for your business. 

So if it's not the time it takes to write notes themselves that's causing the problem, what is?

I've seen one problem come up over and over again... Not ending your sessions on time

Yup, this one thing is so easy to do but it eats up hours worth of productivity. Don't believe me? Let me count the ways, my friend...

Ending sessions late eats into the time you need to care for yourself. When you have clients scheduled back to back and you're not able to take some time to center yourself in between you feel more exhausted at the end of your day. It's go, go, go until the last client leaves. By the end of a day like that, the last thing you want to do is stay in your office and finish notes before heading home.

Even more practically, you may simply be hungry or tired and need to head home because it's dinner time, bedtime, take the kids to swimming lessons time, etc. 

One solution to this problem? Schedule yourself a 30 minute break in the middle of back to back sessions. Decide how best to use this time, whether it's for a walk around the block, taking a nap, grabbing a bite to eat or even catching up on a few notes. 

Now let me say that I do think it's okay to write your notes the next day. If I see clients until 8pm at night, that's what I'm doing! But the moment we put off that task we increase the likelihood that it will get pushed back even further (woops, forgot about that appointment tomorrow morning and then the kid's school thing!) and also that it will be of poorer quality whenever it does get done.

And guess what? It takes longer to write notes when you have to try and recall what actually happened in the session. I know I'm not the only one who has sat in front of a computer screen trying to remember what in the heck was that big thing I talked about in my session at 4pm two days ago. Now, a task that could take five minutes is taking fifteen minutes. And there are 10 more notes to do. 

Ending sessions late also eats into time you could spend on small tasks. One good thing about all of us being on our phones all the time is that you can actually be productive while doing things like waiting in line or sitting in the waiting room at a doctor's office.

Let's say you feel great in between sessions and don't really feel the need to center yourself, go to the bathroom or grab a quick snack. If you see 4 clients in a row and do 50 minute sessions, that's 30 minutes in between you can use to call someone back, confirm an appointment, briefly answer an email... Or even write a progress note!

By contrast, those extra 5-10 minutes you're providing your clients by going over in session aren't likely making a huge overall impact. Of course, there are always exceptions and the occasional session will go over but when this becomes a regular practice, it really takes up your time.

My whole point with using the phrase "meaningful documentation" over and over again is that your paperwork needs to suit your (and ultimately, your client's) needs. Same with your policies and procedures.

If you know you won't be ending sessions on time and don't want the stress, then own it. Plan around it. Use the 30 minute break strategy above. Schedule chunks of time to write your notes when you won't feel stressed about other things. Do what works for you to get the work done well. 

And if you feel like a little help with the technical part of writing is what you need to save yourself some time, check out my free Private Practice Paperwork Crash Course. In that course, I share strategies for simplifying your documentation and identifying templates that work best for you... another great time-saver. 

Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors. 

Paper v. Electronic Records: The good, the bad and everything in between

Probably one of the biggest decisions therapists have to make about their practice these days is whether or not to go with electronic records (i.e. EHR). As with anything, there are benefits and drawbacks to this choice. Since I've had a lot of experience with launching electronic health record systems and evaluating workflows I thought I'd lay out all the pros and cons right here so you can make an informed decision about what's right for your practice. Let's dive in...

Paper Records

Pros:

The biggest pro to using paper is that you can start with it practically for free. Create or purchase a paperwork packet, buy some paper and a few file folders and you're set to go. Very little ongoing cost... although you do need to ensure you have a cabinet to lock all files. 

Another pro to using paper is that you can customize and change your forms at will, without worrying about requirements or limitations of an EHR. You can include a logo/branding to make them look nice and delete or add as many sections as you like. 

The third pro with paper is that some people really do have more of a connection with writing something. Also, if you do a lot of worksheets, artwork, etc. with clients in session it is very easy to throw those papers in a file, rather than scanning and uploading everything you want in the client record

Lastly, most people are familiar with paper. It is easy to set up and you don't have to learn anything new to get started. 

Cons: 

The biggest con with paper records is simply that you have to physically store them for so long! Most of us keep records for seven years (or longer, if you see children/teens) and it's really difficult to tell whether or not you plan to move at all in the next seven years. This can also make things difficult to track after multiple moves.

Related to storage is the fact that things can get lost. With paper records, you're really putting all your eggs in one basket and it's very easy to lose things once you start keeping multiple files. 

Another harsh reality is that files can be destroyed or stolen. I know people whose offices have flooded from a leaky sink not caught over the weekend, people whose offices completely burned down in a fire and people whose computer and other equipment was stolen. These things really do happen and it's unfortunate to lose so much information so easily. 

Lastly, many people simply write much more slowly than they type. Using paper records can be more time-consuming than using a computer to complete paperwork. This applies to both your clients as well as yourself and any employees/associates. In some ways, sharing documents can be easier with paper but it can also be more difficult if you need to fax or scan things that would've otherwise already been uploaded electronically. 

The In Between

So... what if you want to type your notes on a computer, but not use a cloud-based system? Perhaps this seems like the easiest solution. The main benefits here are that you likely already have a computer for work, you won't have to lug around a bunch of files or have an ugly cabinet in your office, and you also won't have to pay for a monthly subscription to keep records. 

However, most of the cons with paper still apply here. Your computer is probably the most likely item to ever be stolen and with this method you're likely putting all your eggs in that one basket. So, if anything happens to your computer (and even us Mac users have heard horror stories of people losing everything based on a glitch or a misplaced cup of coffee), well, you're screwed.

Electronic Records

Before we go over any pros and cons with electronic records, it's important to note that while there are some great EHR's out there, no system is perfect and no system will have everything set up exactly the way you want. With that in mind, let's look at what the general pros and cons include...

Pros:

Probably the biggest pro of using an EHR for your private practice is that all your records are easily housed in one place. You simply log in and voila, everything you need! If you have internet access, then you can access your full client records from any location. Many EHR systems even have apps so you can write a quick note from your phone.

Another huge pro is that having your records in an EHR will likely provide the safest records storage available. While we're all concerned about hackers, and that is certainly something to keep in mind, a good EHR will provide excellent security. This security will be far beyond what you could create for yourself, either using paper or keeping notes housed on your computer.

And because you have easy access to safe storage, many EHR's will safely store credit card numbers for your clients. Roy Huggins has a great article (click here to read) discussing the reasons you probably don't want to collect your client's credit card numbers yourself. Having them write their credit card information on a form you keep is very unsecure. But if you use an EHR that has this set up through a merchant account, they are ensuring the security is up to date and you can ensure you'll be paid. 

If you contract with insurance companies, an EHR can save you tons of time because they typically include billing. While that doesn't mean they're going to call to check eligibility or follow up on rejected claims, they will often submit your claims electronically as soon as you enter the necessary data. Again, everything you need in one place. And if you provide clients with a super bill, most EHR's will print out a nice one for your clients based on the sessions you've entered.

Lastly, another benefit to using an EHR is that many offer client portals. This means your clients can log in to complete and upload paperwork before appointments, and even interact with you securely. This can save worry about email communication or clients forgetting to bring in needed paperwork.

Cons:

The most obvious con with using an EHR is the cost. While most are actually providing an exceptional service for the price, it can still be a stretch if you're just starting out and only have a few clients. This is where it's really important to think through all your expenses and also, your long-term goals. Using an EHR is probably one of the best investments you can make for a therapy practice... but if the money's not there, then it's just not there.

Another con is that despite your best efforts and our tech society, there is still a lot of paper going around. This means you are likely to end up scanning documents every once in a while. For some, this may be just a couple pages a year but for others (and depending on your particular EHR set up) it could mean LOTS of scanning. Consider your clientele- do you tend to work with people who often have reports or require lots of communication with other providers? If so, you'll want to consider a more robust system that allows clients to upload documents. Also, if you have an assistant, this may not be such a big deal.

Lastly, another con with EHR's is that some offer limited ability to customize your documentation. You know this is a big one for me because I believe that you should personalize your paperwork to your client's needs as much as possible. Some EHR's do allow you to create your own templates, some don't, and some charge extra for this feature. This is where shopping around and trying things out ahead of time is crucial. The last thing you want is to get everything set up and then realize the notes or treatment plans are a total pain to work with!

Some Cons to All Methods

One mistake I've seen over and over applies to all records, paper or electronic. That's putting something in the wrong client file. I've seen people physically put the wrong note, release form, etc. in a paper file and I've also seen people accidentally type a note in the wrong client's file within an EHR. Some people have never made this mistake, some people have done it multiple times. Obviously, the key here is to make sure you're taking time to be mindful of what you're doing when writing notes. 

An EHR can save you lots of time and headache, but it can't think for you. So regardless of which method you use, make sure that documentation isn't an afterthought. Instead, let's make it a meaningful part of your practice. 

If you're looking for tips on how to personalize your mental health paperwork, check out my free Private Practice Paperwork Crash Course, where I walk you through different ways of writing notes and treatment plans, as well as what to focus on during intake. 

3 Big Problems Therapists Had in 2014

You know how your clients often get stuck coming in and talking about the same problem session after session? You review with them strategies you've previously discussed or you process why the same patterns seem to continue across relationships and circumstances. And, while every person is unique, you begin to see common themes emerge.

Well, in 2014 I started QA Prep because I noticed therapists asking lots of questions related to clinical documentation... and I started to see patterns emerge. The same questions, over and over again. And I thought, "what if I developed resources for therapists so they didn't have to search all over for answers?" I opened shop in April and spent a lot of time answering emails, responding to questions in Facebook groups and problem-solving over free consultation calls... and here are the main things therapists had problems with in 2014:

Time Management

Did you know the majority, yes the vast majority, of your colleagues struggle to keep up with their paperwork? If this is a struggle for you, you are not alone! This is one of the most common and one of the most destructive problems I see. When therapists think documentation is boring and meaningless, they avoid it or do sloppy work. And once you're behind by one day, it's easy to push things back further... and before you know it, you're a whole month behind on documentation. And then the paperwork to be completed looks like a huge mountain to scale.

The game of catch-up, fall behind, catch-up, etc. becomes a vicious cycle and creates a lot of resentment toward documentation. 

The key is really to be honest with yourself and create a realistic plan. Don't do what your previous supervisor told you worked for them or what the therapist down the hall is doing. Do what works for you! Some people choose one day per week to do all their paperwork, some do notes for every individual in the 10 minutes between sessions, some do notes for an hour at the end of the day. These are all possible strategies to try. The "best way to do paperwork" is whatever works to actually get it done. I would recommend at least creating a weekly plan so that by the end of the week you know everything is complete and don't have to catch up later. 

Insurance

I consistently get a lot of questions about insurance, relating to reviews by the insurance company, how to write notes and treatment plans for insurance, and what CPT codes to use for different sessions. Honestly, the CPT code questions are the most common and also the easiest to answer! Here are the top three...

Q: What code do I use for couples counseling?

A: For insurance and coding purposes there is no such thing as couple's therapy, there is family therapy. Use the family therapy code, 90847, when doing couple work and clearly identify why the marriage counseling is assisting the individual client with his/her mental health needs. This still requires the individual to whom you are billing insurance to have a diagnosis. 

Q: Does insurance cover teletherapy and what code do I use?

A: The answer is, it depends. Some states have required insurance companies to reimburse for telehealth services but some have not. Furthermore, the requirement does not set a standard for payment, meaning the insurance company may reimburse teletherapy at a different rate from your in person sessions. The key is to know whether or not your state is included in this list and to check your individual contract with the insurance company. If you are able to provide teletherapy, use the regular therapy codes with a "GT Modifier."

Q: Does insurance cover (insert service or code here)?

A: Again, the answer is, it depends. Every contract with an insurance company is unique, meaning the therapist in Suite A may be contracted to bill seven different codes/services at a specific rate and the therapist in Suite B may be contracted with the same insurance company to bill nine different codes/services at a different rate! This means the answer to any question about what you can bill lies in your contract. Do not rely on your colleague's experience in this area, make sure to look at your individual agreement. As a side note, this also means that yes, your rates are negotiable... if you want them to be!

Staying Up to Date

Lastly, another concern that is common is figuring out how the heck to stay up to date. Many therapists feel pretty competent in their documentation but after 15+ years in practice they are unsure whether or not they're up to date. Documentation is not a common topic to discuss, especially among seasoned clinicians, and it's easy to start feeling as though you may be missing something. 

The obvious is answer to this dilemma is taking continuing education classes, especially in areas such as ethics, HIPAA, and clinical documentation. Also, join your local and/or state professional association. Their job is to stay abreast of changes in mental health and update their members accordingly. Interestingly, I first heard about the 2013 changes to CPT codes from the California Psychological Association, not my agency or connections while working in quality assurance!

However, another great way to stay up to date is through consultation with colleagues. Choose a trusted colleague and discuss one to two cases together and how you do your paperwork for that case. Better yet, choose a colleague who has recently attained their license and then another colleague who has 15+ years experience. You can also review 1-2 of your client files ahead of time and come with questions. It's a great learning experience and you'll likely gain a few helpful tips from one another!

If you're not sure how to get started with a consultation group, sign up for my monthly newsletter (and get immediate access to my free Paperwork Crash Course), where I review tips on this and other ways to improve documentation. I take a totally judgement-free approach in all my material and I'm always creating new programs for therapists who want rock solid documentation. 

Share in the comments below any other struggles you think are common and we'll problem-solve together!

Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors.

Why Medical Necessity is Important to Private Pay Therapists

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In a previous blog I talked about the term Medical Necessity. Most of you are probably thinking, “Well, that only applies to people who work with insurance companies.” While it’s definitely crucial for people billing to insurance to understand those aspects, I think every therapist needs to have a good understanding of medical necessity. Here’s why:

  1. If your client has insurance and eventually wants to use that insurance for treatment, they will need to show they meet medical necessity. You can never predict if your client may choose to use their insurance. Even if you don’t plan to bill for them or continue services at that point, it will help them tremendously if you can give them (and maybe, their new therapist) an idea of how they meet medical necessity.
  2. Medical necessity is a term used in medical circles. As mental health professionals, it is important we are able to use the same terminology as medical professionals. We need to be able to speak the same language as physicians if we want to work with them in providing quality care and use them as a resource for referrals.
  3. Using the key points of medical necessity is a great way to conceptualize cases! Ethically, we need a clear understanding of our client’s needs and how we can help them. We also need a way to determine if treatment is effective and when it is no longer necessary. Additionally, if you have difficulty conceptualizing a complicated case, try using the medical necessity formula. It will help you narrow your focus. You can see the formula in my previous blog, What is medical necessity and why do I care?

Although private practice therapists are able to have a lot more flexibility in their documentation, using the concepts of medical necessity can help us to use consistent language as a profession and improve our communication with other practitioners, such as physicians. Rather than seeing the term as a box within which we are stuck, we can simply add the concept of medical necessity to our toolbox and resources list.

Are you interested in finding out more about private practice documentation? Sign up for the QA Prep mailing list and get immediate access to my free paperwork crash course.

The biggest paperwork mistake therapists make

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This is going to seem like the simplest advice you’ve ever read, but if every therapist were actually implementing it, I wouldn’t think it was important to write about. The biggest paperwork mistake therapists make is not writing things down.

This could be due to lots of reasons- not having enough time, not understanding what’s important to write about and what’s not, or even choosing to keep certain information out of a client’s chart so it “won’t hurt them later on.”

When writing notes on your sessions and interactions, keep the information really basic, simple, and elaborate whenever you have that “gut” feeling that something was off. This could be a phrase that struck you as odd or out of the norm for your client, even if it wasn’t a clear threat. It could also be something more glaring, like a client’s passive suicidal ideation and any steps you took to ensuring your client is safe.

Another important thing to document (that is sooooo often missed) is things outside of session. A family member calls and leaves you a message about the client’s recent behavior. The client calls you two days after your last session to say “I’m wondering if this is really working out.” A social worker contacts you about a child client you’re seeing because a child abuse report was made by the school.

None of these are things that happened during your session, but they are all just as important to document.

Make sure you are clear about basic things like dates, times and names of who you interacted with but also about why you’re doing what you’re doing. If you’re presented with a grey area, consult with a trusted colleague and write a note explaining your reasoning behind your actions.

Ultimately, you are much more likely to regret a lack of documentation than over-documenting. If you take away anything from this article, or from anything I say ever, take away this: If it’s not written down, it didn’t happen!

Seriously, post it next to your computer or notepad as a constant reminder so your actions are never called into question. And for those sticky situations where you feel you really need help and don't know what to do, schedule a consultation or check out the resources available on the QA Prep website. Happy writing, everyone!