Greetings well charting is grueling and I wanted to do an area dedicated to it. Here we go! I’ve written how patients will be reading your notes according to new laws… I stopped following the updates because everything was about the pandemic… but since writing about charting, I forgot how this process has continued to help me…
I had a pt. request her records and I’m pretty transparent with patients, even if we have a disagreement. He wanted to be put on a medication that caused SI per another psychiatrist and sidebar- I list SI as an adverse reaction… well another provider wanted him to be started on it instead of a mood stabilizer, which I was using to treat the depression, but then he became hesitant because the other provider insisted that he didn’t have bipolar after using a rating tool to prove it… Long story short, I declined to change the medication and we amicably parted ways. However, I encouraged him to read my notes because I explained how I’ve never dx or assumed BPD, the person may actually have it, or a personality/dissociative problem, etc. but I would’ve mentioned it… because I really wanted the patient to understand my concern was coming from a good place especially when it comes to SI. This person was struggling with thoughts and the last thing I wanted was for the person to believe I was smiling in their face, but writing something completely different. There are other reasons to be mindful of what you documented:
- SI or Severe Psych Issues: again I don’t play with major mental problems that can cause significant harm to the person or others… In addition, think about courts, retaliation, or how it may affect others, your credibility, etc.
- FMLA, disability: I have done countless paperwork so I’m speaking from experience and want to mainly say how I usually do this paperwork VERY vaguely… mainly for the sake of privacy (since anyone may have access to it) and for convenience. Work smarter not harder… and if any additional information is needed, they can request records, and most of the time they do so I’m not going to keep couple charting… I tell patients if there’s a problem, they can request records or what specific information is needed. I list some of my vague terms below
- Insurance/For the sake of your profession: when people have issues billing, I simply respond about how is the documentation. This is my response to someone a while ago…when services are not getting covered it may be because of the state (if you need a collaborative physician) and if the collab is not signing off on the services/medications, it won’t get covered. It may be the actual insurance company; state insurance truly doesn’t cover that much. If you continue to have issues with billing you may want to consider switching to cash/credit options. Here’s another secret, sometimes I’ll call the insurance company and actually speak to someone about how things are not getting covered and what to do about it… sometimes it’s a misunderstanding etc. or the clinical note isn’t sufficient to bill for the services. This is my nice way of saying, for the sake of the profession -PROPERLY CHART. I’m not pulling this from my behind, I wrote about some basics:
Additional Pages
I work with another physician that uses an outline format, which is what I’ve changed to, mainly because we have a crappy EMR. However, as long as you have the basics it shouldn’t be a major issue. The purpose here is to specifically address therapy notes, which is another beast. Why is it crazy? Because providers normally don’t do it and according to the general consensus, there’s nothing written in stone. My colleague asked for some assistance and ONCE I’ve helped him out, the rest was history and now he’s enjoying it as well… Here are some tips that have been a game changer for me:
Step 1: Do the therapy intake like a NORMAL intake. This was where my coworker was confused because a patient would just ramble, and if the provider had no direction, it was like a leaf blowing in the wind. Another reason why this is important is how I would be asked to take over their medication management so it truly saves time to already have the information available.
Step 2: Here is the ADDED exception, in addition to the intake, I would add this section at the end and it just went over some general basics. Also, note if I run out of time, I’ll either fill in the blanks based on the intake or ask in f/u or for more clarification (the words in the italics are what I’ll write in the chart):
- Triggers: (or phobias or fears?) i.e. small spaces, large crowds, driving, loud noises, bugs, etc.
- Coping Skills: (how do they deal with triggers or manage them?) -and I’ll ask how have they worked on these issues in the past and the pt. may say i.e. journaling, deep breathing, taking walks, etc. Also note the BAD coping skills i.e. ETOH, smoking, eating, gambling, shopping, etc.
- Goals: even if the pt. doesn’t have them, I usually write what we should be working on… -improve coping skills, mood management/stability, decrease psych symptoms, stress management, improve QOL/ADLS, etc.
- Hobbies: To make the conversation lighter, I usually ask what the person does for fun i.e. videogames, playing with the pet, going to the gym, spending time with family/friends, listening to music, TV, reading, etc, and ask about what kind of books, music, TV, they watch.. You’ll be surprised how many people watching crime shows then get paranoid at night and are always scared…so sometimes they need insight into how their activities may be the root of the problem, triggering, or at least take a break. Sidebar -some people would tell me their hobby is drinking… so whether they think it’s a problem or not, I put bad habits in their “coping skills” because “hobbies” shouldn’t lead to criminal records, deaths, diseases, etc.
- Main Support: so you want to know who is their support system and this mainly affects my older populations. You want to know who to contact/in charge in case of emergencies. I have patients who have no one and it can be difficult because sometimes I have to advocate for assisted living, or sometimes my appointments are wellness checks. For young people, it’s usually the mother, friends, etc., but for the general population, a lack of social support also means how improving coping skills and the goals are imperative.
Step 3: Tell them to get a journal (to prepare them to do homework). Here’s where I get backlash from the patient, like how dare I tell them to do some work. I let them know that I know humans don’t like change because it involves an active process. The brain works by connections, so if you have an addiction or a 20-plus-year/chronic connection, the only way you can change negative thought processes like guilt and shame is to counter it with positive engagement. Some will still ask what’s the point and I usually respond so we can track your mood and thoughts, to see what’s helpful/unhelpful, etc. I also mentioned how it doesn’t have to be a dear diary blah blah blah or a dissertation… I tell them they can write a sentence, a word, draw, etc.
- Sidebar: I also look at writing as a form of decompressing or managing stress… and I try to get the patient to see writing something down like on a scrap sheet of paper, gives you power or some control over these negative thoughts since it’s down on a piece of paper instead of everything hanging over your head like dark clouds, and that in itself is empowering.
Step 4: Noncompliance/Improve Rapport/Comfort Measures. They came back into your office, they didn’t get a journal or they did and didn’t write anything and sat in the chair like now what? Well, continue to improve the rapport and let them know it’s okay. Humans don’t get things on the snap of your finger. I had an older patient who just made up her own assignments, and brought me a comic strip, and we just laughed because I thought they didn’t make those anymore so it was a light-hearted meeting. I had a younger patient who really lacked motivation and didn’t want to do anything, and sometimes I would remind the patient you don’t have to be here. At the end of the day, the terms are on the patient and what they ultimately want to do and I don’t work harder than the patient. THEY need to do the work in order to change (additional considerations: Advice to Remain Sober and The Pt. is Drunk). The only work involved here is to document the noncompliance but continue to go back to improving the coping skills and goals.
Step 5: The therapy note is mainly the conversation around what is/isn’t helping, the past, life changes, or how they are coping. I type as they talk, I get some people want their undivided attention and I was like that as well at first but it just wasn’t time efficient. I would usually ask my patient do you mind as I type while you’re talking, and usually, it’s okay and they’re really understanding. If you did steps 1-4, it’s actually easy to keep up or follow the conversation while typing and I end the note with when the person will RTC (return to clinic) and/or the homework if applicable.
Step 6: What is the homework? of course, it depends on the situation but here’s a general list of examples that they also need to be using their journal or notebook for:
- Write a positive view of yourself: so many people beat themselves up, have low confidence/self-esteem, etc. that I ask the patient to write something positive about themselves. If they write a book, great! but most of the time they’ll only write a few sentences and that’s okay, but I encouraged the patient to go further into details… I get people who want some credit but I don’t want a person to have the habit of doing the bare minimum and thinking it’ll help. IT WILL NOT. If the patient continues to do the bare minimum, these are the ones I recommend doing therapy weekly, but if they’re still reluctant continue to focus on improving the coping skills and goals.
- Write about an incident that’s bothering you the most: this is helpful for PTSD, childhood trauma, intrusive thoughts, or anything that’s reoccurring and goes back to how can the person have power over this guilt and shame or become empowered. I have a personal theory that the more humans get older, if they get more antsy or paranoid it somewhat goes back to having this lack of control. The purpose of writing about whatever incident is not only to gain some kind of control over the emotions but also or mainly to become MORE objective about the situation. It’s like everyone gets older, and has to deal with death or tragedies, etc., and I’m not talking about people with terminal illnesses, what I’m referring to is how not to keep emotionally responding to the negative. I plan on writing more about PTSD and grief, but the goal here is to have stable and rational emotions. People in this category also avoid a lot and that’s also a coping skill that may or may not be negative, it really depends on how rational the person is…
- Write a Letter: this is helpful for wanting to express yourself to someone who’s no longer in contact or in the picture whether it’s for a good or bad reason, the point is it’s another form of decompressing/stress relief.
- Write out a Process: for example, if people are bitter, resentful, angry, etc., I would ask what’s the process of forgiving, moving on, healing, etc. Now the person may say “I don’t know that’s why I’m here”… but I challenge that like well how did you handle your anger before? or how did you forgive others in the past? or how would you feel if someone was angry with you for 40 years?… Don’t let the patient keep going back/forth, they can act stubborn so I act the same accordingly and ask them to write out a process of how they forgave others or dealt with anger before…I had one patient that was like well I’m not religious and I told her it’s not about religion, how do YOU deal with anger. If they care to listen, it wouldn’t be a problem writing out a process/a situation or terms of healing, but if so it just goes back to focusing on the coping skills/goals.
With the above tips, it should start a decent foundation, and below are some downloads and resources. I personally haven’t used worksheets, mainly because the printer acts up… I also try to start with something easy such as writing just to write, because something additional may be more frustrating to the patient. I also worry about how worksheets can take the hard work out of the patient doing it on their own, so it’s pros and cons to them. Nevertheless, I’ve used worksheets, rating scales, and other formats that have been super helpful.
