Behavioral and Mental Health Competency and Need for Support
Federal Law requires psychotherapists to put “minimum necessary information” in a chart note. The important question is, who decides what is the “minimum necessary.” The information that must be in a chart note depends upon who has authority to review the records, and what they are entitled to read. A psychotherapist is required to provide the minimum necessary information. Yet, authorities who are not part of the patient-therapist treatment relationship often expect and set auditing standards that would reveal information that is sensitive, intimate, personal, private and/or confidential. The standards are not transparent and are often hidden by claims that they are intellectual properties.
Newly licensed clinicians, associates, interns and residents who leave public or private agencies where they have worked and trained are often inadequately prepared to practice, legally and ethically. Nor have they been introduced to the types of electronic health records appropriate for private psychotherapy practice, systems that are affordable and designed to support group and individual practices. They are trained to complete forms without understanding the ethical, privacy and legal requirements licensed psychotherapists are expected to uphold.
Licensing Boards have differing expectations and permissibility regarding what is or is not an ethical violation. The curricula of professional programs typically includes little or no information or training about the intersection of ethical standards, healthcare records law, charting requirements, contracting, or professional practice management. Agencies use students and recent graduates who are not paid or paid only moderately well. Some recent graduates choose to enter private practice. Many enter that arena unprepared or very ill-prepared.
Investigations and survey by Mentor Research has learned that as many as 50% of psychotherapists are inadequately informed or have been misinformed about the State and Federal Laws, contracting, claims management, practice management, EHRs, Audits, and documentation requirements. More than 50% of psychotherapists prefer to use paper notes. Many have been offered paper templates for documentation purposes, both by payers and by those who offer training in mental health charting. Those templates are inadequate to their intended purpose. There are more than 64 categories of information and over 2000 options psychotherapists contend with as they create treatment plans, progress and psychotherapy notes.
Training offered nationally, attended by psychotherapists, recommended charting methods which disregard 40 years of research regarding what is necessary for good psychotherapy outcomes. There at least 8 charting methods amenable to psychotherapy charting, yet training continues to focus on time consuming, expensive, and outdated paper-chart strategies that provide no improvement in outcomes.
The GRID
The GRID is a training and charting tool. It can be used to create chartnotes but that is not the only purpose. The GRID is designed to be used as a learning management system to support training and research.
Research. The GRID was initially created as a research tool for the purpose of identifying chartnote independent and dependent variables, generating hypotheses, and evaluating dependent variables. One important research finding was that it is virtually impossible to chart and meet all the documentation expectations of parties who are not involved in treatment. The number independent variables are so large and complex that psychotherapists are seldom trained to meet all the requirements when necessary and in a reliable manner. Unless you have a tool like The GRID, therapists lack the necessary information and time to meet all 3rd party expectations.
Charting. The GRID can be used to rapidly create chartnotes but it is not part appropriate for large scale practice management system. A psychotherapist can use The GRID to convert paper notes to chartnotes quickly. It can also be be used to document complex cases whereby ordinary charting system do not offer the tools available in The GRID.
Training. The GRID was also designed to be a training tool. Without question, anyone using The GRID to create a real patient or an imaginary patient will learn more about charting and especially the requirements to create minimal and high quality notes. They will also learn more about the relationships among content necessary to document standards of practice, medical necessity, etc…