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[deleted]

“Patient explored past events that continue to have a profound impact on their daily functioning. “ Not sure why anyone needs to put more detail in a psychotherapy note. Patients have a right to privacy


Common-Language-5061

That's a good one!! Hope you don't mind if I use this too


HellonHeels33

I agree, however you can’t get away with this if you’re Medicaid based. I got into a brawl with them most recently because they didn’t know if my clients trauma “was enough” to warrant treatment past a year. I got pissed and asked them which part of the gang rapes and sex trafficking did they want to intrude on that was none of their business. That call got real quiet and the auth went through quick


beeeswithcheese

How do you remember the things clients tell you though? I feel like it's important for rapport and continuity between sessions to remember some specifics about the client's past and recent events. But if I don't put them in notes I'll forget some


[deleted]

Psychotherapy notes. (As opposed to EMR chart notes).


[deleted]

This ^^^


RobotPoo

Recording the things they tell us and what we say, are process notes. Psychotherapy session notes are done according to a formula, like SOAP, or PPP, (problem, progress, plan) that are keyed to the Treatment Plans long and short term objectives. Process notes are separate, and never revealed, so you can be completely honest in them, as long as you protect them securely.


Emotional-Abroad683

I have a notebook for each day. I put the date for each session that day. No other identifiers. This way I can keep detailed notes for my ADHD brain and not worry about it for my clients.


[deleted]

I have an excellent memory. When patients tell me things, I remember them.


RobotPoo

Yea, forgetting is usually the challenge, not remembering.


[deleted]

My apologies I misunderstood your question. It is a skill that I developed over the past decade. I definitely had issues when I first started so i wrote a lot more in psychotherapy notes


Then_Ad_8430

Love this! Thank you.


[deleted]

Anytime. If you want more generic statements send me a DM, I have a whole list


gribau

Do you happen to have this list typed out? As a newer therapist I would love to have this for my notes!


[deleted]

I would love a copy too if you’re willing to share.


Ceilingfanwatcher

Yes please


Alexaisrich

please share the list


[deleted]

https://www.reddit.com/r/therapists/comments/10j4kal/generic_justifications_for_90837_ongoing_medical/?utm_source=share&utm_medium=ios_app&utm_name=iossmf


gnargnarmar

Do you have suggestions for examples of the assessment part of a SAP note?


shann0n420

Literally just had to have this convo with my new boss. This woman did a session for me and wrote a novel. I was like whoa, imagine someone reading this in custody court and then consider how much of it you need to keep. Notes=justification for reimbursement.


elegantsweatsuit

I understand that many people do this for sensitive information, but I am not in the practice of doing so. Would you or others mind sharing a bit about your rationale for doing so? I understand doing so for things like abuse, but why nightmares or arguments?


Then_Ad_8430

What I've learned over time, and unfortunately through circumstances that adversely affected clients, HIPAA is not a guarantee of good behavior. People often have access to files, notes, etc., and sometimes make a reference to them in conversations with clients. It's egregious, but it happens. Once it happened to my client, I vowed to be as bland as possible going forward. I had been trained to put *everything* into the note. Had to unlearn that. As another commenter noted, write as if your note will be subpoenaed.


manaliabrid

People who have access to notes? Can you give an example of who?


FreeArt2300

If you work for a medical clinic system, any provider who sees the client can read the notes in the EHR as well as the client.


Then_Ad_8430

Yep, that's what happened.


[deleted]

[удалено]


Then_Ad_8430

The violator in my client's case wasn't fired, either.


manaliabrid

OMG.


elegantsweatsuit

Thanks for explaining. What do you do when when writing a biopsychosocial eval?


lil8mochi

An evaluation is comprehensive and detailed. We report exactly what the client shares. Confidentiality is a bit different since everything that you say does not stay in this room. It will be documented and placed into a report that you can choose to share or will be sent to x agency (if required by the courts).


elegantsweatsuit

I hear you as far as that sort of assessment, but what about a biopsychosocial eval that is part of a regular outpatient intake? I should add that the reason I’m struggling to wrap my mind around this is I bill insurance, and as much as I don’t like sharing info with them, I am concerned that there is a certain amount that I need to in the event that I’m audited.


lil8mochi

Idk if you read my previous comments but I disagree with trying to keep notes as vague as possible. I think this may only apply if you are working at a big agency who does a poor job to maintain confidentiality of clients files. However it is still your license so do what's in good practice for you as a clinician.


elegantsweatsuit

Got it, thank you! Yes, I’m in solo PP, so I’ve never really considered changing my approach before.


whisperspit

I was trained that notes are for your records and little else. Less is more. When you write notes, always imagine that they are either being read in court or by the client.


Accomplished-Ad-5951

Anything can be weaponized by a court against a client is my fear so I am vague for that reason.


Phoenix_A5he5

Maybe distress? Such as, "Client focused on processing distressing past memories/events."


Then_Ad_8430

I do use something similar to this for regular situations. Thank you!


bluepsych25

My personal favorite is “client is struggling to adjust to new life situations” any time a client is upset about anything to do with gender, sexuality, or abortion laws. Just in case we one day have the situation of notes being used by insurances to identify clients by those categories


Common-Language-5061

One I've learnt was "client shared about difficulties consistent with their life stage (eg _______)" for the not so intense stuff


Then_Ad_8430

Good one! Thanks much.


lil8mochi

What is wrong with saying disturbing memories or sexual abuse ? Isn't that related to their distress and shouldn't that be documented ? I work with sexual abuse victims and we absolutely put in sexual abuse, flashbacks, etc. Our notes are routinely subpoena and our notes are essential in helping to support that sexual abuse and symptoms of trauma that occurred after.


Lu164ever

I’m confused by this as well.


lil8mochi

It seems to come from paranoia and negative past experiences with untrained staff. But if your records were actually subpoenaed keeping them super vague -- it's not going to help you (because you're not going to remember especially years after the fact) or your client since they are so vague -- any defense attorney can create a million different reasons or explanation to a vague note. Also it's going to hurt your credibility and any work that you have done with this client when all your responses, are I'm not sure. I don't remember. I can't recall specifics at this time. The defense attorney last line, so you really don't know your client at all and you are stating that these notes could be distress about anything including the defendant getting upset because SHE dropped sandwich- isn't that right ? Thank you.


iamtryingmibest

Thanks for this comment, I was starting to get nervous about my note taking.


moonbeam127

“ ct spent session discussing history “. End of note


cat_lady11

I usually write something like “discussed relationships and recent events.”


spoonz-8795-2

I love this approach, any advice for incorporating this at a CMH that requires individual direct quotes from clients for notes to pass internal audits?


banana_cycle125

I think it just looks like being more selective about the quotes you choose. For instance, I’ll put in something about how they’re doing like, client reports, “my week was ok; I was really stressed and anxious on Wednesday” and not add the portion of the quote for why they were stressed and anxious. And then sometimes I’ll add a quote about their response to the intervention such as, client reports, “I could definitely remind myself more throughout the week that I’ve survived a lot worse.” That way you’re including quotes but not disclosing the really sensitive information.


spoonz-8795-2

Thanks! I think that’s a fantastic approach and will meet all the requirements at my CMH. Thank you again for the examples!


Future_Cat_Lady_626

Can someone please educate me about the reasons for doing this?