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What is the Value of Charting in Psychotherapy Practice?

  • There is no empirical evidence to support assertions made by Healthplan payers and EMR vendors that the inpatient style and detail of a comprehensive record is an appropriate standard for outpatient psychotherapy.

  • Manualized treatment is not empirically supported as more effective than non-manualized treatment. While manual‐based treatment may be attractive as a research tool, it should not be promoted as being superior to non-manualized psychotherapy for clinical practice.

  • First and foremost a psychotherapist must chart in a way that informs and benefits care as it begins, unfolds, and ends. The second purpose is to document those appropriate services were provided in a manner that can measure outcomes, patient satisfaction, and is useful to physicians treating a patient for associated problems.

  • To create chart notes that meet the information expectations, and needs of all potentially interested parties, is impossible given the constraints of private psychotherapy practice.

  • There is no empirical evidence that patients or the public benefit from disclosure of sensitive, intimate, personal or private information required in writing by interests external to psychotherapy. There are no studies that examine the benefits and harm caused by psychotherapy chart notes.

  • Courts of law have repeatedly supported the position that psychotherapy cannot work without privacy and confidentiality.

  • Parties such as health plan payers, judicial systems, managed care businesses, and other healthcare providers who are not part of psychotherapy treatment often assert they have a rightful interest in what takes place in psychotherapy sessions, even though the interest they assert does not contribute clinical value or enhance the quality of treatment.

  • There is no empirical “underpinning” to suggest there is a link between “good clinical practice” and “level of record keeping.”

Psychotherapists in private practice frequently question the value of treatment plans and chart notes based on standards created by interests external to the therapy, standards which often have little to do with processes or outcomes that matter to patients.

In 2003, Andrea Neal published her dissertation titled The Impact of Written Treatment Plans on the Effectiveness of Psychotherapy in a University-Based Community Clinic.

Subjects were randomly assigned to the experimental group where written treatment plans were developed collaboratively with the client following a treatment planning protocol, or to the control group where subjects received treatment as usual, generally with no written treatment plan.

It was hypothesized that subjects within the experimental group would show greater functioning and improvement in symptom reduction at the last time period, and they would indicate a stronger therapeutic relationship and greater satisfaction.

Repeated measures ANOVAs of the OQ scores, comparing the two groups at the first and last assessment, showed that both groups improved over time. There were no significant differences between the two groups in amount of improvement, except that subjects in the treatment as usual condition showed greater improvement, at post-test, in interpersonal relationships compared to experimental condition subjects.

In 2014, Michael King, published an article titled Clinical Record Keeping in Psychological Practice - Complete, Accurate, Ethical? In that article, he points out that there is a

…missing empirical underpinning to the links between “good clinical practice” and “level of record keeping”. Accepting that all of psychological endeavour is aimed at providing evidence-based pronouncements and practices, and further acknowledging the pivotal Natural Justice importance of accusation based upon evidence, it remains unclear what weight should be ascribed to strident “Expert” statements proffered in the absence of published studies providing relevant evidence.”

The absence of empirical evidence linking volume of record keeping to practice outcome leaves open the conclusion that the Expert pronouncements on this topic are examples of Galtonian “sacred impressions” which have not been held up to cold-blooded verification.

In 2014, Emil Kirkegaard stated,

General impressions are never to be trusted. Unfortunately when they are of long standing they become fixed rules of life and assume a prescriptive right not to be questioned. Consequently those who are not accustomed to original inquiry entertain a hatred and horror of statistics. They cannot endure the idea of submitting sacred impressions to cold-blooded verification. But it is the triumph of scientific men to rise superior to such superstitions, to desire tests by which the value of beliefs may be ascertained, and to feel sufficiently masters of themselves to discard contemptuously whatever may be found untrue.

To read more, Cited in Arthur Jensen: Consensus and Controversy. Vol. 4. Routledge, 1987.

If the question of charting were to be seriously examined and studied, the null hypothesis would be: There are no significant differences in outcomes and patient satisfaction between psychotherapists who chart to a high volume and those who chart at a low volume. As of the time this article was written, no such studies are referenced in numerous authoritative texts that review outcome studies and the relevant factors that predict outcomes.

In 2018, Femke Truijens, et al., stated based on a systematic review of the literature that,

…institutional promotion of psychotherapy manuals as a requirement for evidence‐based treatments (EBTs) yields the assumption that manualized treatment is more effective than non-manualized treatment.

Their systematic review examines empirical evidence for this claim. They concluded that,

Manualized treatment is not empirically supported as more effective than non-manualized treatment. While manual‐based treatment may be attractive as a research tool, it should not be promoted as being superior to non-manualized psychotherapy for clinical practice.

What helps bring about change for psychotherapy patients is not enhanced by documentation requirements imposed by third party payers, professional associations, or training institutions. There is no empirical evidence to demonstrate that treatment plans and progress notes as required by interests external to psychotherapy improve outcomes, patient satisfaction or the quality of outpatient psychotherapy.

What are the practice purposes of psychotherapy chart notes?

The following is based on a paper authored by Stephen Behnke, published by the American Psychological Associations Ethics Office.

According to Stephen Behnke:

From a clinical perspective, keeping a record provides a history that a treating psychologist can review to further the treatment and help meet the client's clinical needs. Psychologists vary widely in their clinical use of a record; some take detailed notes, others are sparse in their approach.

From an organizational perspective, keeping a record may facilitate the efficient and effective administrative provision of services, for example, in a setting where the organization, rather than a specific treater, is considered the provider or is responsible for ensuring that clients receive the services to which they are entitled.

From the perspective of reimbursement, an accurate record allows the party responsible for payment to confirm the nature and dates of services. The specific payment context--managed care, Medicaid, or private insurance, for example--may have its own record-keeping requirements.

From a legal perspective, state or federal law may require that a record be kept. What the law requires varies according to jurisdiction. Some states are nearly silent on the issue, while others are specific in what a record must contain (see Kansas regulation 102-1-20, for an example of greater specificity). Other states explicitly allow a psychologist not to keep a record under certain circumstances (see for example Washington state regulation 246-924-354(g).

From a risk management perspective, keeping a record may be the standard of care. Also, documenting one's thoughtful and reasonable work may protect the psychologist in an ethics committee, licensing board, or court proceeding, should an action against the psychologist arise. Some courts have held that for the purposes of litigation, a fact finder may assume that the record reflects the totality of service provided; from this perspective, what is not documented did not occur.

The Ethics Code makes clear that record-keeping is not an end in itself. Rather, keeping a record serves multiple goals. The more a psychologist has examined the reasons behind keeping a record and has considered how those reasons fit together when applied to his or her own practice, the more likely it is that the record will convey a coherent, useful history of the treatment--a history that will serve both the psychologist and the patient well.

In private practice psychotherapy the clinical purpose of a chart note is to document:

  1. that a service was provided to justify charging a fee for that service.

  2. that patient/s and psychotherapist discussed pertinent patient history and presenting problems for which services are requested and qualify for reimbursement.

  3. pertinent aspects of patient functionality, symptoms, well-being, health, and risk factors which impact provision of an appropriate level of care.

  4. information that allows the patient and psychotherapist to define when continuation or termination of care is appropriate.

  5. any need for other or additional services.

  6. the outcome of services provided.

Who believes they have a right to psychotherapy information?

Parties who are not part of psychotherapy treatment often assert they have rightful interest in what takes place in psychotherapy sessions; even though the interest they assert does not contribute clinical value or enhance the quality of treatment.

External parties’ influence often function as attempts to limit or direct services by promoting record keeping criteria which may create both liability and ethical risk for clinicians. Such pressure may lead psychotherapists to set aside ethical and professional responsibilities to patients; choosing to take the path of lowest risk by declining to see patients who are high risk.

No So Smart Charting 1.JPG

Psychotherapists assert that external parties assume they are entitled to written records of what is happening in psychotherapy. Each external party has a unique argument and purpose for what they expect to see in a psychotherapy note. Invariably such requirements are disruptive and over time can change therapy process and outcome in ways that do not benefit patients.

Courts of law have repeatedly supported the position that psychotherapy cannot work without privacy and confidentiality. And yet external parties want patients to expect that intimate and personal information will be documented. Many patients become concerned when they learn that psychotherapy records can be subpoenaed for all manner of purposes such as divorce, an injury claim, a disability determination, background checks, or a child custody battle. These purposes interfere with the patient-therapist alliance that is necessary to provide effective psychotherapy.

Following a groundbreaking court ruling in California, professional associations began to provide training that asserts there are exceptions to privacy and confidentiality in psychotherapy when the safety of the public or vulnerable individuals is at risk. In such cases a psychotherapist may have a duty to take appropriate action to protect others or the public from harm without reporting to external interests. Permission to report and take action to protect makes sense ethically and morally. That should not open the door to agendas which have nothing to do with patient care or public safety, such as corporate ambitions, profits, market share, political agendas or religious beliefs.

The point here is that psychotherapists continuously encounter the assertions of people outside the treatment relationship who wish to insert their influence into private and confidential matters and argue they are entitled to private, personal and sensitive information. Their reasons have no value to psychotherapists or patients.

Outside interests argue that their intent is to protect the public thereby protecting the patient as though there is a downstream effect. This “protection” is often presented as a false narrative that there is a fixed “pot” of money which must be shared among an increasing number of patients who need psychotherapy on an asserted “basis of need”. Businesses that make more profit by spending less money on psychotherapy do this by requiring psychotherapists to document detailed personal information as testament and proof that services are “medically necessary.” This can have a perverse effect, leading, for example, to an auditor’s insistence that psychotherapists describe in detail the day-to-day behavior of a person diagnosed with depression. Worse, that psychotherapists must inquire into the patients bio-psycho-social history even if that history is unrelated, personal, private and sensitive. Such violations can make patients uncomfortable and suspicious of their psychotherapist.

There is no evidence that patients or the public benefit from disclosure of personal, intimate, or private information required in writing by interests external to psychotherapy. More important, psychotherapists believe that requirements to make disclosures that are irrelevant to psychotherapy services often interferes with, disrupts, and undermines the psychotherapy process. Interviews solely for the purpose of gaining comprehensive information to justify treatment can feel like a pushy interrogation to patients. Conversations that reveal information in a natural way build trust, confidence and a solid alliance between therapist and client.

Psychotherapists argue that the level of documentation required of psychotherapists is not in any way comparable to that necessary for physicians who are detailing physical injury, making referrals for surgery, or allowing an illness or injury to heal naturally.

There is nothing to record about the psychotherapy process as important as accurate records of medication benefits and side effects reported to physicians and documented in medical charts. Accurate records of medication response and physical symptoms can be matters of life and death, particularly in hospital settings. However, psychotherapists are reluctant to record patient medications and dosages because they are no way to verify the patient’s potentially misleading reports. Psychotherapists find that their professional associations offer trainings which, intentionally or not, rely on a false equivalency between physical medicine and psychotherapy. Implied or asserted requirements that psychotherapy records should meet the standards of medical records instills fear in psychotherapists who wonder what might be deemed negligent if they do not chart to the level of detail required of a physician and others providing inpatient care.

Why are documentation requirements useless and a waste of resources for clinical practice?

A third-party does not interview patients to determine the effectiveness of services. Third-party payers demand evidence from providers concerning the need for and effectiveness of mental health treatment. The position of Healthplans can be summarized as follows:

  1. A skilled therapist who is effective and provides justifiable services can, on paper, be deemed ineffective or fraudulent based on the sole reason of inadequate/incomplete documentation.

  2. Healthplans assert that documentation requirements are (a) uniformly simple, (b) can be completed quickly, (c) are easily learned, and (d) can be completed with brevity.

  3. Services provided in-network or out-of-network can result in denial of payment.

  4. Healthplans, attorneys and investigators may assert “If it wasn’t written down, it didn’t happen.” This opens the door to allegations of fraud.

  5. Healthplans may assert that services are not medically necessary if a patient can behave in a functional manner .

  6. Healthplans can assert that treatment of mental health symptoms may be helpful but that the symptoms are not problems unless they interfere with measurable daily living skills and responsible behavior in life.

  7. Healthplans can deny services if a psychotherapist does not document the onset, frequency, antecedents, intensity and duration of symptoms, as well as the functional impairments.

  8. Healthplans can deny payment for a legitimate diagnosis if there is not observable and measurable dysfunction.

  9. Healthplans can deny payment if specific discharge/termination criteria are not written into the treatment plan.

Conflicting purposes create psychotherapists’ discomfort

There are perspectives one should evaluate when considering arguments about the value of detailed psychotherapy notes.

  • Chart notes are processes that may take time away from treatment.

  • Compliant records may simply demonstrate that services are adhering to the requirements of outside interests, not the patient or the care provider.

  • Psychotherapists experience cognitive dissonance when creating detailed chart notes to meet external expectations.

  • Psychotherapists are spending many thousands of dollars’ worth of their time charting to meet expectations irrelevant to outcomes or patient satisfaction.

  • There is perverse impact of incentivizing psychotherapists to protect themselves from the invasive requirements of people who have authority over their professional futures.

  • Psychotherapists resist the perverse and especially irrelevant requirements of external parties.

Psychotherapists question perverse influences from external parties, as does any person subjected to external rules, requirements, and expectations deleterious to their values, sense of morality, professional goals or life purpose. Psychotherapists, social psychologists, and economists generally agree there are undesirable consequences when outside authorities create policy, rules, or regulations that have perverse impact on processes and decisions, and negative impact on people who care for and work to help others.

Educators and social scientists recognize psychological principles that define the struggle with which psychotherapists contend. These social and psychological principles are Campbell’s law, The Cobra Effect, and Goodhart’s Law.

Campbell’s Law

Campbell's Law is an adage developed by Donald T. Campbell, a psychologist and social scientist who often wrote about research methodology.

Campbell’s Law states:

The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.[1]

The Cobra Effect

The cobra effect occurs when incentives designed to solve a problem end up rewarding people for making it worse. It is also known as the perverse incentive.

Goodhart's Law

Goodhearts Law Statistical.JPG

Goodhart's Law is an adage named for British economist Charles Goodhart, who advanced the idea in a 1975 article on monetary policy in the United Kingdom.

Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes.

A classic example of Goodhart’s law discusses hospital waiting times. In theory, the waiting time at a hospital is an indicator of how efficient that hospital is. So, a good hospital providing prompt care for patients will generally have a short waiting time for treatment. Consequently, hospital waiting times are defined as a reasonable metric for determining the level of service and thereby the quality of healthcare provided. But when that metric, the waiting time itself, is used as a target for hospitals to meet – as it has been by many governments – hospitals are inevitably incentivized to cut waiting times regardless of any effect that workflow shift may have on the overall quality of healthcare offered in the hospital.

Goodhart’s Law Generalized

Anthropologist Marilyn Strathern generalized Goodhart's law beyond statistics and control to evaluation more broadly. The phrase most commonly cited as “Goodhart's law” appeared in a paper of Strathern's, not in Goodhart's writings:

When a measure becomes a target, it ceases to be a good measure.

“Target” is another word for “requirement”.

Who has the right to know and influence what happens in psychotherapy?

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Educational institutions make their income by educating students. Larger student populations generally mean more income and better education outcomes when the curriculum is appropriate. But that is no guarantee for reasons mentioned above. Many educational systems graduate students who can pass examinations and complete practice internships but are woefully unprepared to practice psychotherapy. Students unprepared for private practice are often employed in public health or large private agencies where their caseloads involve the most serious problems and are extraordinarily high (200 or more cases).

Counseling, Social Work and Psychologist licensing boards are empowered by each State to protect the public. Professionals who have had no licensing complaints are viewed as being more appropriate caregivers than those who have had complaints. It should come as no surprise that there is perverse incentive to avoid seeing patients who are high risk. This avoidance may include patients who are suicidal, violent, severely mentally ill, children during a divorce, people who have committed a crime, people who are divorcing, children in protective custody, or people who have federally funded health insurance. Why work with people who are paranoid, hallucinating, unable to control rage, suicidal, abusing alcohol, engaged in child custody battles, have no job, involve themselves in riots, or believe COVID-19 is fake news? Why treat patients whose care is federally funded when any failure to document far more than is necessary or helpful may be considered unethical, fraud or criminal, rather than an irrelevant omission?

Lack of “adequate” charting when a therapist is contracted with a commercial health plan may be a “contract violation” and would be dealt with as a civil matter. A commercial payer’s audit which finds inadequate information may result in requirement that the therapist return money paid for services and lose the contract as part of a negotiated plea or court judgement. A health plan cannot pursue chart-keeping matters as criminal issues when therapists disagree about the adequacy of their records.

However, an auditor for State or Federal Government, examining State or Federal health care expenditures, can refer any hint of fraud to an investigation for criminal prosecution. Professional liability insurance does not cover defense of criminal prosecution. Individuals and clinics have gone bankrupt while defending their records systems even when no fault is finally found. In such situations, no compensation is paid to an exonerated therapist or clinic. Psychotherapists should be very afraid if their case load is largely covered by State or Federal payment. Psychotherapists are vulnerable in many ways but particularly because no comprehensive descriptions of record standards are published for State or Federal audits. What few guidelines are available are not adequately informative for purposes of avoiding the consequences of an audit. To create chart notes that meet the information expectations and needs of all potentially interested parties is impossible given the constraints of a private psychotherapy practice.

Healthplans, State and Federal Courts each assert that businesses and the public have a right to mental health records under a rule of law. This can include a right to records for use in child custody evaluations, for criminal defense, as support for injury claims, for assessments of competence, as information to support or refute complaints to licensing boards, or to support qualification for disability services or funds. The records made available for such actions can be retained indefinitely by individuals, businesses, and government agencies.

What are the oversight purposes of psychotherapy charting?

Can psychotherapists chart patient services to appease external parties with minimal harm to patients?

First and foremost a therapist must chart in a way that informs and benefits care as it begins, unfolds, and ends. At the same time therapists should consider that chart notes address the following issues per requirements of parties external to the services provided:

  1. Billing information

  2. Contractual requirements

  3. Legal requirements

  4. Ethical requirements

  5. Clinical thoroughness

  6. Medically reasonable & necessary requirements

  7. Practice policy

Image 1. Excerpt from “There is a S.M.A.R.T. Way to Write Management Goals and Objectives”, by George Doran. (November 1981)

Image 1. Excerpt from “There is a S.M.A.R.T. Way to Write Management Goals and Objectives”, by George Doran. (November 1981)

In Oregon, when reviewing OAR 410-172-0630 (2)(c) psychotherapists see this statement with regard to services they provide:

(2) (c) Provided in accordance with an individualized service plan and appropriate to achieve the specific and measurable goals identified in the service plan;

The above referenced regulation is a source of consternation to psychotherapists. The solution presented by health plans to private practice psychotherapists are based on requirements for employees working in residential, inpatient and intensive outpatient treatment programs. For example, during communication with the behavioral health quality manager of an Oregon Coordinated Care Organization (CCO), the manager stated,

I strongly encourage the use of SMART goals on Service Plans to be compliant with this OAR: Specific, Measurable, Achievable, Realistic, and Time-based. (the manager was referring to [OAR 410-172-0630 (2)(c)])

This recommendation is echoed by some health plans. However, S.M.A.R.T. was developed by George T. Doran at which time had nothing to do with effective mental health treatment. In November 1981, Doran’s article There is a S.M.A.R.T. Way to Write Management Goals and Objectives was published in Management Review (AMA Forum).

S.M.A.R.T. was a model for writing goals and objectives was developed and was at the time used in business management, project management and for personal goals management. The purpose is well stated in the final point in Doran’s paper illustrated in Image 1.

S.M.A.R.T became the defacto model of charting for agencies, residential and inpatient treatment programs which must adhere to Joint Commission Standards PC.4.40 (Behavioral Health) and PC.4.10 (Hospital). Under PC.4.40, an organization develops individualized plans for care, treatment, and services that reflect the assessed needs, strengths, and limitations of each patient. The purpose of chartnotes are to serve provider who work in shifts 7 days a week, 24 hours a day.

Joint Commission Standards PC.4.40 (Behavioral Health)

PC.4.40 - The organization develops a plan for care, treatment, and services that reflects the assessed needs, strengths, and limitations.

Joint Commission Elements of Performance require treatment plans to include:

  • Clearly defined problems and needs statements

  • Measurable goals and objectives,

  • The frequency of care, treatment, and services,

  • Objectives are specific to evaluate the client's progress and expressed in behavioral terms that specify measurable indices of progress

  • Goals and objectives are re-evaluated and, when necessary, revised at a minimum specified time interval established by organization policy.

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The above elements of the organization’s performance have been conveyed to individual psychotherapists contracted with the Oregon Health Plan; recommending a treatment plan that includes the following:

  • Specific: Objectives need to be clear and specific, not general or vague. It's easier for a patient to complete objectives when they know exactly what they need to do.

    Measurable: Objectives need specific times, amounts or dates for completion so you and your patients can measure their progress.

    Attainable: Encourage patients to set goals and objectives they can meet. If their objectives are unrealistic, it may decrease their self-confidence or discourage them. However, goals and objectives should not be too easy either. Goals should be challenging but also realistic.

    Relevant: Goals and objectives should be relevant to the issues listed in the treatment plan. When patients complete objectives and reach their goals, they should be closer to the place they want to be in life and as a person.

    Time-bound: Goals and objectives must have a deadline. Goals might be considered short-term or long-term, while objectives need specific dates to meet. A deadline creates a sense of urgency which helps motivate clients.

The SMART way is a method intended to manage the business end of services provided (i.e., between the provider and the employer). How an employer evaluates a psychotherapist is not the strategy psychotherapists use to manage and evaluate patients’ care. This is important. SMART is not a clinical process to improve psychotherapy outcomes and patient satisfaction. It’s merely assumed and asserted that it does on a basis of ‘face validity. Which means, it sounds good but may not be true, or it does not have any predictive validity nor provide any value to a patient.

Psychotherapy research has accumulated a great deal of evidence that patient outcomes and satisfaction have nothing do with charting in a specific manner. The most authoritative references make no mention and offer no empirical evidence that charting “quality” is related to quality outcomes. And that makes sense because S.M.A.R.T. charting is not a quality measure of psychotherapy but rather a business tool to structure the business of managing the activities of people who provide healthcare. It encourages managers to supervise the work of psychotherapists by focusing on patient-therapist interactions described in chart notes rather than more useful, reliable, and valid quality, outcome, and satisfaction measures.  Overtime, the SMART charting process used to hold psychotherapists accountable became a strategy to manage and hold patients accountable.  These oversight strategies result in activities by psychotherapists that can waste time, and cause premature patient dropout.

Image 2. Practice Treatment Planners published by Wiley Press.

Image 2. Practice Treatment Planners published by Wiley Press.

There have been numerous publications pertaining to treatment planning and charting. The most prolific authors are Arthur Jongsma, Mark Peterson and William McInnis. They have, to date, published 36 “Practice Planners (see Image 2.)

Highly detailed psychotherapy treatment plans and progress-note requirements originated in hospitals, residential treatment programs, and clinic practices where records are shared among providers.  

Jongsma asserted that detailed psychotherapy treatment plans benefit treatment because managed care insisted on them.  Jongsma asserted that treatment planning and chart notes serve continuity of care.

According to Jongsma, et al,

Every treatment agency or institution seeks ways to increase the quality and uniformity of documentation in the clinical record.  A standardized, written treatment plan with problem definitions, objectives, goals, and interventions in every client’s file enhances uniformity of documentation. This uniformity eases the task of record reviewers inside and outside of agencies. Outside reviewers such as The Joint Accreditation Commission of Hospitals (JACHO) insist on documentation that clearly outlines assessment, treatment, progress, and discharge status.

Treatment plans for inpatient and residential and multi-disciplinary clinic settings serve specific purposes.  Treatment in these programs may be in process 24 hours a day, 7 days a week. A well-crafted treatment plan that clearly stipulates presenting problems and intervention strategies can facilitate treatment processes carried out by team members in inpatient, residential, and intensive outpatient settings. Good communication among team members about what approach is being implemented and who is responsible for which or what intervention is essential. At any time, a treatment provider coming on duty may not have met a patient or not seen that patient for days.  Such clinical records are intended to be used by people who work in shifts and take days off.

A treatment plan must be well detailed in an inpatient or residential setting to ensure continuity of care.  The information gathered must serve multiple purposes, supporting the roles of nurses, physicians, physician assistants, social workers, counselors, psychologists, family, art, and occupational therapists as they interact with patients.

Despite decades of pressure on outpatient psychotherapists to provide comprehensive and detailed chart notes such as those required in inpatient and intensive outpatient settings, there is no empirical evidence to support assertions made by payers that the inpatient style and detail of a comprehensive record are an appropriate standard for outpatient therapy. Such record keeping patterns are largely irrelevant to the processes of outpatient psychotherapy. 

Psychotherapists who have practiced for many years will tell you that requests for records and subpoenas are not common. Further, there is seldom a chart note adequate to meet the purported purpose of the request.  Worse, documents maintained for clinical use can easily be misunderstood or deliberately misinterpreted by attorneys, health plans, disability analysts, triers of fact, juries, parents, or guardians. 

Psychotherapist’s notes typically serve no clinical purpose for future care.  Virtually anything consequential in psychotherapy vital to a patient’s well-being can be determined retrospectively by interviewing the patient or reviewing case summaries created when treatment was terminated.  Anything consequential to a therapy that needs to be recorded can be preserved in a termination note.

Conclusion

The purpose of a chart note is to allow audit of a psychotherapist’s process, hold the psychotherapist accountable, and to document a psychotherapist’s decision whether care should be continued, increased, limited, or terminated.  

References

Key words: Supervisor education, Ethics, COVID Office Air Treatment, Mental Health, Psychotherapy, Counseling, Patient Reported Outcome Measures,