Prototype Mental Health Records

Abstract

This chapter provides detailed recommendations for the style and content of mental health practitioners’ clinical case records covering specific content domains and other important issues in record keeping aside from content (e.g., release, retention, security, and disposition).

Key words: medical records, record keeping, release of records, disposition of records, record security.

This article describes a recommended style and content for mental health practitioners’ clinical case records covering specific content domains and other important issues in record keeping aside from content. Not all of the content information described here will be necessary for every record, nor would one expect to complete a full record as described here during the first few sessions with a new patient. By the end of several sessions, however, a good-quality clinical record will reflect all of the relevant points summarized below.

I have framed this article as though writing for other psychologists, however it applies equally well to other mental health professionals. It may also offer a useful guide for patients who wish to review their own records. Under the Health Insurance Portability and Accountability Act (HIPAA) patients have a right to see and get copies of their health information, or share it with a third party, such as a family member, other health care providers. 

Please note that this article refers only to clinical records, not “psychotherapy notes.” Such notes are accorded special protections. Therapists need not keep this category of note, but if kept they are filed separately from any clinical records. Patients may still seek access to them (if they exist) or release them to others separately from other records. The HIPAA definition of such notes follow:

“Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.”

This article updates an earlier version that appeared in the Psychologists' Desk Reference (2013).

GENERAL REGULATORY ISSUES

Depending on the nature of the records (i.e., business records, health records, or educational records) a range of state and federal laws may apply including regulations of the Internal Revenue Service (IRS), and requirements of the Health Insurance Portability and Accountability Act (HIPAA) or Family Educational Rights and Privacy Act (FERPA). Web site links at the end of this chapter will guide readers to specific regulatory policies of the IRS and for HIPAA and FERPA covered entities.

CONTENT ISSUES

·        Identifying information: Name, record or file number (if any), address, telephone number, sex, birth date, marital status, next of kin (or parent/guardian), school or employment status, billing and financial information.

·         First contact: Date of initial patient contact and referral source.

·        Legal notifications: The Health Insurance Portability and Accountability Act (HIPAA) requires that patients be given specific notifications regarding privacy and other matters (discussed elsewhere in this volume) at the initiation of the professional relationship. Some states have parallel or more extensive requirements, and the APA Code of Conduct specifically requires psychologists to notify patients about the limits of confidentiality at the outset of the professional relationship. Such notice will generally cover limitations on confidentiality, including mandated reporting obligations (e.g., child, dependent persons, or elder abuse and neglect) that apply in the practice jurisdiction. Provision of this notice, ideally by means of a signed notice form, should be noted in the record.

·          Notification of fees and billing policies:  Document notification of fees, fee increases, any fee agreements, and billing practices if these are not already covered in other notices given to the patient at the beginning of the professional relationship. Note any special circumstances such as sliding-fee agreements, retainers, plans to bill for missed appointments, barter transactions, or special fees in a manner that reflects the patient’s understanding and agreement in advance of incurring charges.

·          Relevant history and risk factors: Take a detailed social, medical, educational, and vocational history. This need not necessarily be done in the very first session and need not be exhaustive. The more serious the problem, the more history you should take. Get enough information to formulate a diagnosis and an initial treatment plan. Be sure to ask: “What is the most impulsive or violent thing you have ever done?” and “Have you thought of hurting yourself or anyone else recently?” Seek records of prior treatment based on the nature of the patient (e.g., the more complex the case, the more completely one should review prior data). Always ask for permission to contact prior therapists, and consider refusing to treat patients who decline such permission without giving good reason (e.g., sexual abuse by former therapist).

·           Medical or health status: Collect information on the patient’s medical status (i.e., When was his or her last physical exam? Does the patient have a personal physician? Are there any pending medical problems or conditions?). This is especially important if the patient has physical complaints or psychological problems that might be attributable to organic pathology.

·           Medication profile: Collect information on all medications or drugs used, past and present, including licit (e.g., prescribed medications, alcohol, tobacco, and over-the-counter drugs) and illicit substances. Also note any consideration, recommendation, or referral for medication made by you or others over the course of your work with the patient. In some circumstances (e.g., non-abusive use of marijuana; legal in some states but not under current Federal law), you may wish to record this in psychotherapy notes, but not the clinical record in order to afford patients the maximum privacy allowed.

·          Why is the patient in your office? Include a full description of the nature of the patient’s condition, including the reason(s) for referral and presenting symptoms or problems. Be sure to ask patients what brought them for help at this point in time, and record the reasons.

·          Current status: Include a comprehensive functional assessment (including a mental status examination), and note any changes or alterations that occur over the course of treatment.

·         Diagnostic impression and disability rating: Include a clinical impression and diagnostic formulation using the most current DSM (Diagnostic and Statistical Manual of the American Psychiatric Association) or ICD (International Classification of Diseases of the World Health Organization) model. Do not underdiagnose in a misguided attempt to protect the patient. If you believe it is absolutely necessary to use a “nonstigmatizing” diagnosis (e.g., an adjustment disorder) as opposed to some other diagnostic label (e.g., psychosis), use the R/O (rule-out) model by listing diagnoses with the notation “R/O,” indicating that you will rule each “in” or “out” based on data that emerge over the subsequent sessions. Your diagnosis must also be consistent with the case history and facts (e.g., do not use “adjustment reaction” to describe a paranoid hallucinating patient with a history of prior psychiatric hospital admissions). Using an inappropriate diagnosis can suggest either incompetence or intent to mislead. Avoid using the obsolete Global Adaptive Functioning (GAF) scale formerly rated as Axis V in the DSM. If you wish to note disability factors or if your patient seeks to apply for a Social Security mental disability use the World Health Organization Disability Assessment Scale (WHODAS 2.0).

·       Treatment plan: Develop a treatment plan with long- and short-term goals and a proposed schedule of therapeutic activities. The plan should be updated every 4 to 6 months and modified as needed.

·        Progress notes: Note progress toward achievement of therapeutic goals. Use clear, precise, observable facts (e.g., I observed; patient reported; patient agreed that . . .). As you write, imagine the patient and his or her attorney looking over your shoulder as they review the record with litigation in mind. Avoid theoretical speculation or reports of unconscious content. Do not include humorous or sarcastic personal reflections or observations. Your record should always demonstrate that you are a serious, concerned, dedicated professional. If you must keep theoretical or speculative notes (e.g., impressionistic narratives for review with a supervisor), use a separate “working notes” format, but recognize that these records may be subject to subpoena in legal proceedings.

·        Service documentation: Include documentation of each visit, noting the patient’s response to treatment. In hospitals or large agencies, each entry should be dated and signed or initialed by the therapist, with the service provider’s name printed or typed in legible form. It is not necessary to sign each entry in one’s private (i.e., noninstitutional) case files, since it is reasonable to assume that you wrote what is in your own private practice files.

·        Document follow-up and correspondence: Include documentation of follow-up for referrals or missed appointment, especially with patients who may be dangerous or seriously ill. Retain copies of all reminders, notices, or correspondence (including telephone messages and e-mail) sent to or on behalf of patients, and note substantive telephone conversations in the record.

·        Obtain consent: Include copies of consent forms for any information released to other parties, or for other forms of recording (e.g., consent to record interviews).

·       Termination: Include a discharge or termination summary note for all patients. In cases of planned termination, be certain that case notes prior to the end of care reflect planning and progress toward this end.

NONCONTENT ISSUES

·        Control of records: Psychologists should maintain (in their own practice) or support (in institutional practice) a system that protects the adequate control over and confidentiality of records. Clear procedures should be in place to preserve patient confidentiality and to release records only with proper consent. The specific medium used (e.g., paper, magnetic, optical) may require special considerations to assure utility, confidentiality, and durability. For example, a locked file cabinet may suffice for paper records, but digital records will require secure computing environments, encryption, and appropriate back-up. Practitioners must assure that they have taken reasonable steps to assure the security of patient records and should review their practices in that regard regularly as record keeping and storage technologies evolve.

·        Multiple-patient therapies:  When treating families or conducting group therapy, records should be kept in a manner that allows for the preservation of each individual’s confidentiality in the event that a release form arrives for the records of only one party.

·        Adequate supervisory oversight: Psychologists have responsibility for construction and control of their records and the obligation to assure that the people they supervise, whether administrative support staff, clinical staff, or trainees also exercise appropriate practices.

·        Retention of records: Psychologists must remain aware of and observe all federal and state laws that govern record retention. In the absence of clear regulatory guidance under law, the American Psychological Association (2007) recommends maintaining complete records for 7 years after the last clinical patient contact for adults and for 3 years after any child patients reach age 18. Many practitioners store electronic files or paper case summaries for longer periods.  All records, active or inactive, should be stored in a secure manner, with limited access by others appropriate to the practice or institution.

·        Outdated records: Outdated, obsolete, or invalid data should be managed in a way that assures no adverse effects will result from its release. Records may be culled regularly so long as this is consistent with legal obligations. Records to be disposed of should be handled in a confidential and appropriate manner. Never alter or remove items from a record that has been subpoenaed or is otherwise subject to legal proceedings.

·        Death or incapacity: Psychologists need to make arrangements for proper management or disposal of clinical records in the event of their death or incapacity. This would include identifying potential custodians and providing information on accessing the records (e.g., keys and passwords). Ideally, this can be accomplished with a professional will.

References

American Psychological Association. (2007). Record keeping guidelines. American Psychologist, 62 993-1004. Available at: https://www.apa.org/practice/guidelines/record-keeping.pdf

Koocher, C. P., & Keith-Spiegel, P. C. (2016). Ethics in psychology a: Professional standards and cases (3nd ed.). New York: Oxford University Press.

Koocher, G. P., Norcross, J. C., & Greene, B. (Eds.). (2013). PsyDR3: Psychologists' Desk Reference (third edition), New York: Oxford University Press.

Internet Sites

ACCESS TO HEALTH RECORDS: https://www.healthit.gov/faq/how-can-i-access-my-health-informationmedical-record

DSM 5: https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596

FERPA: https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html

HIPAA: https://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html

IRS RECORD KEEPING: https://www.irs.gov/businesses/small-businesses-self-employed/how-long-should-i-keep-records

PSYCHOTHRERAPY NOTES: https://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/index.html

 WHODAS 2.0: https://www.who.int/classifications/icf/whodasii/en/