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. 

How to Personalize Your Intake Assessment Form

Whenever I meet with clients for the first time, I make sure to have a form with me so I stay on track. Even though I've done tons of assessments using the same form, it's so easy to miss something important when I don't have that friendly reminder. 

Having a good intake assessment form is crucial to doing a good intake assessment. Ideally, the form simply serves as a means to guide and document your clinical conversation. It's a valuable tool in the moment, and also if you need to remember things down the line. 

That being said, creating the form can take a bit of work to individualize and then there's the task of familiarizing yourself with it so you actually focus on the client during your intake, not the form

That's why we're breaking things down in this post. I'm going to review with you each of the sections of the intake form in my Therapist's Perfect Paperwork Packet so you can identify which sections in your form you may need to add more detail or which areas to take away some extraneous information. 

Note: People use different terms for this form but the form I'm talking about is your clinical assessment, or biopsychosocial assessment, completed during the intake phase of treatment (typically, the first 1-4 sessions). 

Client Contact Information

You may have this elsewhere in your intake paperwork but I like having some details on client demographics directly on the assessment itself. How in depth you go depends on the information you feel is important to your practice. You'll at least want to include basic contact information, emergency contact information and how to best reach your client (including whether or not voicemails and texting is okay). 

Other things you may want to consider are languages spoken, ways in which your client found you, military rank/position, email, work phone number, etc. Think about the things you wish you had asked before or info you found helpful and include that.

About You

I like having a section that allows the client to describe themselves a bit. This way you get to see the language your client uses for things like hobbies and interests. You can also ask for personal strengths or for preferences. You may want to ask about things like typical screen time or favorite games if you see children. 

I also include a section here for clients to describe their goals for treatment. This way you get to see what their thoughts are about therapy in general and why they've come to see you, in particular. This serves as a great starting point for discussion.

Family History

Gathering information about family history is very important for determining the level of familial support a client has, as well as potential indicators for patterns of behavior. You'll want to identify key relationships, especially those that include an aspect of dependence like care-taking for children or elderly parents. 

One important thing to consider here is that everyone has a different definition of family. I always include a question about "who lives at home?" so I capture anything I may be missing. You may also want to go more in-depth and have clients describe (or circle options) about their level of closeness with different family members. 

Employment/Education History

This area may change greatly based on your client population. Obviously, if you see children you would choose to focus more on the education aspect. However, you may want to include a question about the parent/guardian's occupation. 

We can get even more detailed here: If you see children who tend to be involved with special education services, you may ask more detailed questions about behavior at school, classroom setting, previous grade retention, etc. But, for example, if you tend to see adolescents with anger problems you may focus more on interpersonal interactions ask about suspensions.

When working with adults, employment can sometimes indicate being part of a sub-culture, like with people in the military. In this case, consider questions that would be client specific but potentially impactful to treatment. In the military example, you may want to ask about rank, length of stay in current assignment and any deployments.

Or perhaps you see women who often describe themselves as "stressed" and so you choose to add a question about typical hours spent at work each week and/or a rating of their current work stress. Likert scales are very easy to use here (e.g. a range from "Very Stressed" to "Not Stressed").

Hopefully, you're beginning to notice how all of these questions easily intertwine with the clinical topics you'd want to discuss during your assessment phase and also allow you to see how this process can naturally flow, rather than just sound like paperwork review.

Medical History

This is another topic that will vary greatly depending on your typical client population. If you work with elderly clients, for example, you may want to ask more detailed questions about medical history. Likewise, if you work with couples who are having difficulty with their sexual relationship you'd want to make sure each member of the couple has had a physical exam very recently. 

This is also where you'll want to get information about your client's physician and psychiatrist, if applicable. Many insurance companies particularly look for you to gather this information so you can collaborate as a treatment team.

Mental Health Treatment History

One of the key things to consider with new clients is whether or not they've been in counseling before. This is important to discuss as you inform clients about what it's like to work with you and whether or not you'll be a good fit.

See what we're doing now? We're integrating informed consent with our intake assessment! Documentation is such a beautiful thing ;)

What are their feelings about coming to counseling? Have they had negative or positive experiences in the past? Are they hoping to revisit similar issues or focus on something very different? What did they like (or dislike) about their previous experience and what did they find helpful? 

You may not include all of these questions but consider what typically arises with clients when you discuss these things. What would be helpful to have clients consider ahead of time so you can address it easily during intake? Those are the questions to include. 

Substance Use History

Again, depending on your typical client you may add more or less detail here but regardless, it's very important to cover with clients. If you see clients where this is a common issue then you may have a whole page where ask people to identify use of certain types of drugs, daily or weekly amount of use and prior use. 

You'll also want to ask about whether or not your client is connected with any other support, like a peer support group or substance rehabilitation program. If so, you'll also want to consider whether or not it may be appropriate to consult with these professionals and how your client feels about that. 

Other

There are plenty of other topics to discuss with your clients but you can't know it all before you actually begin the work. The consideration here is whether or not you think it's something to know from the outset or decide if it's something that may come up naturally during the course of treatment. 

Topics also included in my intake assessment form are things like religious affiliations, spirituality, coping skills and favorite habits for self-care. I also include a question on whether or not a client has ever been arrested and if they have a current parole/probation officer.

Another important thing to consider (that may also be part of your informed consent) is whether or not your client is currently part of any litigation/court case. Definitely something you want to know as early as possible so you can review any potential conflicts or expectations of the client.

So whether you prefer to create your own form from scratch, revise whatever you have now, or purchase my Paperwork Packet, you've got plenty of options for how you can make the intake process individualized to your clients and your practice. 

That's my biggest piece of advice for every aspect of your documentation... make sure it actually makes sense and isn't completed "just to do it." Paperwork has meaning but that's only as deep as the meaning you assign it. 

What other topics do you include in your intake form? Comment below and share your own tips!

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.

The Mountain of Paperwork in Community Mental Health

Mountain of Paperwork

Clinical documentation- mention it to most therapists working in community mental health and they will cringe. Along with that word comes mental images of being flooded with redundant paperwork, staying late to write progress notes (or worse yet, working from home), and having supervisors identify endless corrections needed. Few clinicians or supervisors will tell you they enjoy this aspect of their job. Fewer still will tell you they felt prepared for the demands of government-contracted requirements through their training in graduate school. Yet, ask any therapist with a client who has attempted suicide and they will tell you (perhaps begrudgingly) this is one of the most important aspects of their work. 

Clinical documentation is invaluable when we need it most. Progress notes document our efforts to contact clients exhibiting high risk behaviors. Consultation notes document  standard of practice and a rationale for our actions when “grey areas” appear. Mental status exams and assessments document the client’s history of symptoms and provide a course for treatment. Clinical documentation is a necessary tool for therapists working in the revolving door of community mental health. 

However, many therapists find the paperwork difficult to maintain. They don’t see the connection between the clinical work and the forms they’re required to complete. They feel drained and overwhelmed by the daily paperwork requirements. 

If you are a clinician working in community mental health and find yourself becoming overloaded with paperwork, try following some of these steps:

  • Prioritize your paperwork according to it's importance.
  • Talk with your coworkers to see what tips they find useful.
  • Do your best to keep interactions with your coworkers positive.
  • Decide from the beginning that you will NOT fall into the trap of “fudging” the time you bill by 10-20 minutes here and there.
  • Be honest with yourself regarding your strengths and weaknesses.
  • Engage in self-care.
  • Stay connected with your colleagues.

Make sure you talk with your supervisor from the beginning about your struggles to get the support you need. Seek out extra training and consultation. Your agency may offer refresher trainings or, if you’re in the L.A. area, you can check out the upcoming workshop I’m doing on documentation (trust me, I try to make it as fun as possible!). You can also sign up for the QA Prep Newsletter (and get access to my free paperwork crash course) to get tips on making documentation easier and more relatable. 

Don’t be afraid to evaluate different job options if you find you’re a round peg trying to fit into a square hole. When you’re less stressed, you’re providing better care for your clients. Keep the focus on being the best therapist you can be- in all aspects of your work and don't be afraid to ask for help when you need it. Happy writing, everyone!!

Why Medical Necessity is Important to Private Pay Therapists

Advice Help Support And Tips Signpost Showing Information And Guidance

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!

What is Medical Necessity and why do I care?

Medical necessity is a term used by insurance companies to determine if a client needs services, and what services are appropriate. If a client “meets medical necessity” then services are approved! If not, you get that dreaded denial letter. Each insurance company has their own definition of medical necessity, but there are usually three main components:

  • Diagnosis
  • Impairment
  • Treatment Plan

Diagnosis- Most insurance companies want to see a DSM diagnosis for clients to quality for treatment. It is not enough to randomly list a diagnosis (and also not ethical). You need to identify the client’s symptoms to show they meet the DSM criteria.

Impairment- People can live with a diagnosis and not really have an impairment. But, when symptoms start affecting a person’s work or personal life, they need treatment. An impairment is an area of life that is negatively impacted by the client’s diagnosis. Example: The client is depressed and has low motivation and difficulty concentrating which impacts their ability to complete tasks at work and they are now on probation.

Treatment Plan- We’ve identified that the client needs help. Now, what are we going to do about it? It’s the therapist’s job to show the client and the insurance company how they plan to help. Will you introduce certain topics or coping skills, will you use an evidence-based practice, etc. Check with the client’s insurance company, because you may need to identify how many sessions you think this will take.

Medical necessity is a great way to conceptualize your client’s needs and how you can use your expertise to help. If you’re billing to an insurance company, it’s a requirement. If you still need help, sign up for Maelisa’s newsletter and check out QA Prep’s Facebook page for more helpful tips.