(p. 49) Typical Forms Used in a Private Practice
Filling out forms in the practice of mental health treatment can lead to a variety of reactions ranging from complaints about the time and effort required to much relief after a successful audit. If writing the information requested on forms is viewed as being for the sake of nothing else but “more paperwork,” indeed it can seem like a waste of time and effort. Forms must have a purpose that is clearly conveyed to both the practitioner and client as a positive tool in providing efficient treatment. A combination of proper training in documentation and an understanding of how forms can be extremely helpful tools in several aspects of mental health treatment often leads to treatment that is more on target.
Forms, in themselves, are not an end product; rather, they are a means of collecting information for documentation and can be of great help to clinicians in gathering and recording needed information for providing high-quality clinical services. Further, the specific information and data collected on forms is the evidence needed for adequate documentation, which is the result of integrating the information collected on mental health forms. For example, an auditor will examine the information collected on the forms to verify the documentation in areas such as the diagnosis, impairments, content of sessions, and medical necessity. Attempting to gather and record all relevant information from and about clients without the benefit of the types of forms described in this chapter can be a much less efficient and effective process, possibly leading to oversights and having consequences for the quality of the clinician’s documentation and for the quality of the services provided to clients.
Too many practitioners put off filling out forms, and by the end of the week, they spend the good part of a day trying to remember what took place in previous sessions for their progress notes. Filling out forms is not meant to be a punishment or lead to resentment for the time it takes to fill them out. Many experienced practitioners have learned that when forms are filled out entirely during the session with a client, very little or no out-of-session time in needed. What is (p. 50) better, filling out forms between sessions, or relaxing to prepare for the next client? This answer is not difficult. This process holds true for completing intake notes, progress notes, treatment plans, and even testing. However, many experienced clinicians do not fill out client information during the sessions and are able to keep up with their documentation. The choice is a matter of circumstances, preference, and time management.
One of the yearly goals I have for interns every year is that when they conduct a psychological evaluation, they have the bulk of the tests scored by the time the client is finished with the interview and testing. The report is then dictated immediately, before the next client shows up. The transcriptionist then has no more than three days to type the report. Referral sources love to receive a full psychological or neuropsychological report in less than one week. One of the biggest reasons for a practice’s growth is public relations and great customer service (see Chapter 24, “Optimizing Customer Service in Private Practice”). The proper use of forms clearly accelerates the process.
There are pros and cons for filling out forms during the session. The process works quite well primarily in areas of assessment and individual psychotherapy, which have been the focus of my experience. However, there are other areas of mental health treatment in which it may not be feasible or possible. For example, for clients who are in extremely hostile or highly affective situations, writing notes for much of the session could seem rather impersonal. There is certainly no “one size fits all” in any aspect of life, especially in the mental health field. In addition, the clinician’s personality, training, cognitive style, and time availability are important factors in deciding when to fill out forms.
Although I write notes such as client quotes, observations, endorsements of symptoms, and other clinical data during a session with a client, most of the time is not spent in writing. That would seem fairly impersonal. I make as much eye contact as possible, but when I make notations I make sure that the client knows that everything he or she says to me is important. This can be accomplished both verbally and/or nonverbally. For example, when a client says something that is important or clinically relevant, I often nod my head, while making eye contact, and then write it down. I cannot remember every important thing that was said or observed during the session. My notes, the evidence of symptoms, impairments, progresses, setbacks, and need for services, then become much more clearly documented. Nonverbally, I am trying to get the message across as, “What you are saying is very important, so I need to write it down.” In a sense, it can translate to a form of empathy and understanding. I have never had a client object to my taking notes during a session.
Forms do not control any aspect of the diagnostic or therapeutic process; doing an efficient job of filling out forms, and subsequent documentation, has little or nothing to do with being a successful practitioner. However, forms can be very helpful to even the most experienced practitioner in arriving at a documentable diagnosis, following the treatment plan, demonstrating the effects of treatment, and ensuring that ethics and legal requirements have been meet.
This chapter is not filled with sample forms, but rather it provides a framework as to what forms—or information contained in forms—are necessary for building and maintaining a productive and ethical mental health practice. Developing forms can be quite time-consuming, yet many practitioners make their own to best suit their practice. This chapter focuses on the forms necessary to cover the financial, legal, ethical, and clinical needs of a mental health practice. Clinics with specialized services, such as substance abuse, eating disorders, couples counseling, and much (p. 51) more, must simply incorporate additional intake and progress note information to fit the criteria for their specialty. In addition, the various regulatory agencies typically require several forms that are not typically used in a small to moderate-size private practice.
There are plenty of sources for purchasing established forms (e.g., Wiger, 2009; Zuckerman, & Kolmes, 2017). There is not room in one chapter to go over every possible form and handout that could be used in mental health clinical practice, but the main forms typically used in treatment are discussed in this chapter. In a book of mental health forms, Wiger (2009) provides over 60 forms for possible use by practitioners. Clearly, no clinic would use that many forms, but due to the size, specialty areas, accreditation requirements, and other factors, many forms that are not needed by most clinics would be helpful in others.
Five categories of forms, necessary for a practice to run smoothly, will be discussed: (1) pretreatment forms, (2) required HIPAA compliance forms, (3) assessment forms, (4) progress notes during treatment sessions, and (5) posttreatment forms. Other forms, such as those for practice management, are not the subject of this chapter.
It is necessary to collect client information prior to initiating mental health services for several reasons. It is a risky practice to begin treatment without collecting payment information, the reason for referral, and the severity of the client’s impairments; matching the client with an appropriate clinician; choosing appropriate assessment procedures; and informing clients of their rights. The information contained on three forms listed below can be very helpful in preventing both financial loss and a mismatch between the practitioner and client.
It is crucial to inform the client or whoever is responsible for services about the practice’s financial policies. This information can be discussed on the phone but should also be covered in a Financial or Payment Policy Form and signed by the client before services begin.
Several years ago, in the beginning stages of private practice, I did not have a contract for payment of services. I had no signed agreement that if insurance or another third party did not pay, the client would be responsible for the cost of services. Most of the time, when insurance did not pay for all or a portion of the services, I would bill the client and receive payment. However, about one out of four or five clients refused to pay, stating that we should have checked their insurance. A few clients, in fact, stated that since there was no contract, they were not responsible for those fees. Since we had no signed agreement related to those fees, we lost. I learned the lesson the hard way. Now, each client signs a Financial Policy Form and a Payment Contract for Services. The financial aspect of mental health is no different than any other business. Too many private practices have gone out of business due to lack of business acumen. It is important not to forget the following:
If you want to help people, the practice doors must stay open.
If you want your doors to stay open, you must pay your bills.
If you want to pay your bills, you have to collect money for the services you perform.
If you want to collect money, you need sound financial policies.
(p. 52) Form 1: Client Information Form
The Client Information Form is designed to collect information about how services will be paid for and the reasons for requesting treatment. Often, clients will contact a practice to schedule an appointment, yet they may know little about the services provided and whether the practitioner is a provider for their insurance company. This information can be provided in a brief screening by phone. Many clients are unaware that not every practitioner is a provider for every insurance company. Although it is ultimately the client’s responsibility to check this information with his or her insurance provider, the client might not be aware of the process. If they are participating providers, practitioners must decide whether they will contact the client’s insurance provider to verify coverage. The Client Information Form should indicate that the client explicitly authorized the clinician or office staff to verify benefits. Insurance companies typically provide information such as whether the client is current in his or her coverage, the deductible and co-pay amounts, covered services, and which services will need a prior authorization. However, providing a summary of coverage is not a guarantee of payment. For example, providing psychotherapy to a client who does not have a psychiatric diagnosis is not likely to be reimbursed. Most insurance companies initially pay for a diagnostic assessment, a certain number of counseling sessions, and perhaps some testing procedures. However, assuming that these services are covered can be a costly mistake.
Besides providing information to verify insurance benefits, the information collected from the client on this form also helps the practitioner decide if she or he, or at least one of the psychotherapists in the practice, has the professional training and experience to treat the client (referred to as “professional competencies” or “clinical competencies”). For example, if no one in the practice has a professional competency in treating individuals with substance abuse, it is suggested that a potential client with this need be referred elsewhere. It is clearly unethical to provide services without the previous training and supervision needed to provide competent professional service. Thus, determining this before treatment is provided to a new client is essential.
I recall a recent incident in which a client phoned and made an appointment with a psychotherapist. They spent over one hour in a diagnostic interview. By the end of the interview, the clinician told the client that he was not experienced in this client’s issues. He then referred the client to another psychotherapist at a different clinic specializing in the client’s area of concern. The problem that developed was that the original psychotherapist and the second psychotherapist each billed the insurance company for the diagnostic interview; since the deductible amount was not yet met, each bill went to the client. The client then filed a complaint stating that the first psychotherapist “ripped me off.” This could have been avoided by collecting the appropriate information before services began, or at least offering an initial free consultation. The point is that if appropriate information had been collected prior to seeing the psychotherapist, it would have been known that there would have been a mismatch.
A Client Information Form, completed prior to providing any services, should contain the following types of information. It is often collected from one of two sources, the client (or responsible party) or the referral source. The following is an outline that should be tailored for the psychotherapist’s specific practice. A primary goal is to obtain enough information to be sure that there is a match between the client’s needs and the psychotherapist’s professional competencies. (p. 53)
1. Client’s full legal name
2. Current address
3. Phone number(s)
4. Date of birth
5. Type of service(s) requested
a. Assessment (specific type)
b. Treatment (specific type)
6. Specific purpose of seeking services. List specific areas of concern under headings such as:
a. Mental health
b. Behavioral issues
c. Cognitive issues
7. Questions or concerns to be addressed
8. Payment information
c. Third party, not insurance
9. Special requests
a. Practitioner’s gender, age, experience, mode of treatment
b. Appointment day, time
10. Emergency contacts
If the intended payment is by insurance, after this information has been collected, the insurance company or third-party payer should be contacted to verify coverage if you are a provider. Expiration of insurance coverage, lack of payment of premiums, changing jobs, or a number of other factors can lead to cancellation of benefits. Never assume that a client has insurance that is in effect simply because an insurance card was produced or the policy number was given on the phone. Verification of insurance coverage does not verify that the service provided will be covered; for example, the diagnosis may not reach medical necessity or be covered. Some clients do not even know that their insurance coverage has lapsed.
Form 2: Financial Policy Form, with Payment Contract
Just as practitioners should expect to be paid, consumers have the right to know the practitioner’s financial policies. Typically, these are contained on two separate forms (Financial Policy Form, Payment Contract), but they can be combined.
Financial policies must be written in clearly understood terms that are not ambiguous or difficult for the client to understand. Important topics include, but are not limited to, who is ultimately responsible for payment of services such as if a third party denies payment, when (p. 54) payments are due, and methods of payment. The policies should include statements noting that having insurance does not guarantee that benefits will be paid for some or all of the services provided. Never guarantee anything from an insurance company or any third-party payer. The client’s policy is between the policyholder and the insurance company, not your practice. Thus, make it clear that simply because the practitioner is a provider for an insurance company, it is not a guarantee of payment. In addition, make it clear to the client in the Payment Contract that any services provided that are not covered by the insurance company or third-party payer are the client’s responsibility.
Without a payment contract the practitioner might not get paid. Because requirements differ by state, the contract should is reviewed by a business attorney before using it with clients.
True Informed Consent for Professional Services in the contract also includes the following information:
1. The hourly rate of pay for listed services (e.g., intake, testing, individual psychotherapy, group psychotherapy, report writing time, plus other services provided)
2. Missed appointment and late cancellation policy and fee
3. Separate listing of fees for services not covered by the third-party payer (e.g., insurance payment covers less testing time than that which was required, report writing time, extra counseling sessions beyond the scope of the insurance coverage, specific types of treatment or evaluation not covered by insurance)
Include the estimated insurance benefits with a clear notation that these benefits are not guaranteed by the practice, but they are what was quoted by the client’s insurance company, and are not a guarantee of payment.
Required Health Insurance Portability and Accountability Act (HIPAA) Compliance Forms
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is designed to protect consumers’ health information and sets standards regarding the sharing of information. See http:/www.hhs.gov/ocr/privacy/ for a full set of rules established by HIPAA (U.S. Department of Health and Human Services, 2003). Practitioners who do any electronic (p. 55) communication of Protected Health Information must use the following forms to be HIPAA compliant.
Form 4: Privacy of Information Policies (HIPAA Required)
This notice can be posted and handed out to clients. It describes the clinic’s legal duties to the client, how information is legally shared, and when confidentiality can be broken, such as in cases of duty to warn and protect, public safety, abuse, prenatal exposure to substances, in case of a client’s death, professional misconduct, judicial proceedings, minors/guardianship, collection agencies, professional consultations, typing/dictation services, couple/family/relationship counseling, telephone calls/answering machines/voicemail, and other provisions. The form also covers the client’s rights to receive, review, restrict access, and other means of reviewing and disseminating the records. Additionally, instructions are provided as to how to lodge a complaint toward a service provider. Some practitioners have separate forms for each of these procedures.
Form 5: Request to Amend Health Records (HIPAA Required)
Clients have the right to request an amendment in their records if they believe it to be inaccurate. The form includes information as to what amendments to a client’s records are to be made and to whom the amendments will be sent.
Form 6: Request for Restricted Use/Disclosure of Records (HIPAA Required)
The client or the representatives of the client may request a restricted use of disclosure of her or his records. For example, the client may request that only certain portions of the record be shared or that the records can be used for only certain purposes. The form includes the reasons for requesting the restrictions. The service provider reviews the request and notifies the client of the decision.
Form 7: Request for Alternative Means of Confidential Information (HIPAA Required)
This brief form, signed by either the client or his or her representative, is a request for the practice to communicate information to a different address or phone number than the typical residence of the client.
(p. 56) Form 8: Release of Information Consent Form (HIPAA Required)
Except for HIPAA exceptions, a written release of information is necessary to disseminate client information. When using a Release of Information form, the client requests that information is sent from one source to another, but not back and forth.
A Release of Information form minimally contains the name of the client, who will send and/or receive the information, and what information will be disclosed. HIPAA regulations require that a separate authorization is needed for the release of psychotherapy notes—that is, one cannot release psychotherapy notes if a release form states, “send entire record.” However, HIPAA discourages requesting the entire record of clients. Rather, it is good practice to request the minimum amount of information necessary for the stated purpose of the release. Consents expire in one year unless the client authorizes the release for a shorter period of time. The form also includes the purpose for which the material will be disclosed, statements regarding the client’s rights, and legal guidelines. If the client is a child or has a guardian, the guardian must sign. Obtaining proof of guardianship is suggested.
Form 9: Record of Requests for Client Information (HIPAA Required)
This brief form, generally kept in the client’s file, is a record of any requests that have been made for information about the client. Requests from both inside and outside the practice are recorded.
Assessment forms are intended to assist in gathering information in the initial interview sessions that identifies the client’s diagnosis and medical necessity for psychotherapy or other services. Now that background information and legal requirements have been followed, it is time to see the client.
Unless the nature of the visit is a one-time crisis intervention, usually one to three sessions are spent in collecting information to assess the client’s need for treatment, diagnosis, and type of (p. 57) treatment and to develop a treatment plan. A well-conducted diagnostic assessment session with the client can be quite therapeutic because the nature of the questions asked, coupled with empathy and understanding, often lead to the client feeling understood and trusting the practitioner. The same relationship and therapeutic skills employed in psychotherapy are necessary when conducting the initial interview. Thus, assessment is not simply a series of questions and information gathering. Clinical observations and the client’s level of cooperation and insight are crucial to arriving at a proper diagnosis. For this reason, I am not a fan of primarily using checklists filled out by the client for the initial assessment. Never assign a diagnosis primarily based on checklists filled out by the client or others.
Although the diagnostic assessment is not intended to be psychotherapy, it is often an excellent time to build rapport and prepare the client for psychotherapy. I recall several incidents in which clients have been referred solely for a diagnostic assessment. As the interview progressed, and the questions became more personal, clients have often stated that the assessment, in itself, was therapeutic because the flow of information gathering increased their level of insight about their behaviors and mental health.
Assessment forms vary significantly depending on the specialties of the clinic. Various specializations (e.g., children, teens, adults, eating disorders, attention-deficit/hyperactivity disorder, behavioral issues, sexual concerns, chemical dependency, neuropsychological evaluations, learning disabilities, and any of the scores of possible specialties) each have an assessment form that is tailored to their area of focus. The following description of a Diagnostic Assessment Form is generic. Thus, a practice would add items pertaining to its specialty.
Form 11: Diagnostic Assessment Form
The information contained on this form is what determines the diagnosis, medical necessity for services, and treatment plan. This is one of the first pieces of information requested by an auditor or clinical supervisor. It contains all of the information necessary to begin treatment. The information is collected on the first session, usually taking one to two hours.
During this first session, the clinician initially goes over the material written on Form 1, the Client Information Form, to be sure that the practitioner and client agree as to the purpose of the services being rendered. Then, much more specific information is collected to further validate the need for services and what specific treatment will take place.
All humans have some level of mental health concerns, such as feeling depressed or anxious some of the time. These are normal human emotions. It is expected that sometimes a person will have a change in appetite, become irritable, feel angry, not follow through with a task, or experience decreased self-esteem. A collection of “symptoms” is necessary but not sufficient to validate a “diagnosis.” A mental health diagnosis may be given when it is documented that the mental health symptoms of a diagnosis are at least at a level of discomfort, for mild levels of diagnosis, or functionally impairing, for more severe levels of diagnosis. The most important information to be collected is a clear documentation of the medical necessity for services, especially if the payment is from an insurance company. The concept of “medical necessity” refers to the diagnosis and treatment of an illness or symptoms that meets the prevailing standards of care. Thus, the (p. 58) documentation needs to clearly describe personal distress or functional impairments that are due to a mental health disorder.
Insurance companies typically do not pay for services without a mental health diagnosis. It must be noted that a mental health diagnosis is not simply an endorsement of symptoms. This is the first of two parts needed to validate a diagnosis. As per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013), and its predecessors, and the ICD-10 (CDC, 2016), for a diagnosis to be clinically significant, there must be a threshold of acuity in which the effects of the mental health disorder must result in clinically significant impairments in social, occupational, or other areas of functioning. The level of treatment is determined by the severity of the impairment. Thus, mental health forms must include space for (a) information that validates the symptoms of a diagnosis and (b) examples of the resulting distress or impairments due to the mental health disorder.
Some practitioners provide a different amount of documentation for clients depending on the requirements of the third-party payer. For example, third-party payers such as insurance companies, the VA, Social Security, state and county agencies, schools, or any other entity paying for services could require varying types of documentation material. Private-pay clients do not typically have any requirements for the forms used or for subsequent documentation, unless they want to submit for reimbursement on their own. While it can be tempting to “loosen up” on documentation, good documentation and the use of forms are part of providing quality care. I can recall several incidents over the years in which clients paid cash and never mentioned that the results of their assessment or treatment would eventually be used for purposes such as a court hearing, applying for disability, to obtain services, or a variety of other reasons. At times, the request for records occurred a few years after services were conducted. However, because the same set of forms and documentation principles were used for the private-pay client, the information in the file was clear rather than a vague memory.
The following are essential areas where information is gathered from clients using the Diagnostic Assessment Form. This form provides a useful format for the preparation of written reports.
Demographic information includes primarily identification information such as name, address, phone number, and any other client information requested if there is a referral source.
The physical description information is provided mainly for identification purposes. There are rare times in which a different person will attend the appointment. This could be due to someone using someone else’s insurance benefits, or perhaps for monetary gain. I often conduct disability evaluations for various agencies and have on more than one occasion discovered that the person being interviewed was not the true client. There are actually fraudulent businesses in which people (p. 59) pay others a portion of their financial settlement if they pretend to be the client at the interview. These people “know how to answer the questions” correctly to obtain financial benefits. Therefore, checking the client’s identification can be necessary in some situations.
History of Present Illness
Many mental health diagnoses require symptoms to be prevalent for a specific time period to arrive at the diagnosis—for instance, major depressive disorder (two weeks), persistent depressive disorder (one year), and generalized anxiety disorder (six months). Besides the time period, a detailed history of events, circumstances, examples, and consequences of mental health and behavioral concerns are helpful in establishing both a pattern of symptoms and mitigating factors.
Beside listing current mental health concerns, include a history of mental health and behavioral concerns such as how they have affected the client’s functioning over time. Descriptors such as the “OFAID procedure” (Wiger, 2012)—(O) Onset, (F) Frequency, (A) Antecedents, (I) Intensity, and (D) Duration of symptoms and impairments—are very helpful in determining the degree and chronic effects of the client’s mental health concerns.
Collecting a history of the client’s education is much more than just demographics. Information such as highest grade or degree attained, grades, attendance, behavioral concerns, reasons for leaving school, functioning level, and future plans provide helpful information about the client’s level of motivation, cognitive functioning, and behavioral history. An educational history can be very helping in estimating the client’s premorbid level of functioning in cases such as head injuries, various illnesses, and declines in mental health functioning.
It is important to obtain information about employment because it is an excellent indicator of the client’s historical level of persistence, ability, and employment stability and provides a fairly accurate estimate of his or her level of premorbid functioning, similar to educational functioning, noted above. For example, if a client has a master’s degree and successfully held an executive position for over 20 years but suffered a head injury and current testing noted a full-scale IQ of 80, it would be reasonable to deduce that his current testing suggests significant cognitive declines. However, if the client previously left school in the ninth grade, due to poor academic performances, and had never held a job for more than a few months, a full-scale IQ of 80 would fall within an expected range. Without obtaining an accurate history, it is very difficult to know the client’s level of premorbid functioning in many areas of functioning.
For clients coming in for counseling, evaluating the employment history is quite important. Assessing factors such as the average length of employment, typical reasons for leaving a job, (p. 60) attendance history, ability to relate to co-workers and authority figures, and any other aspects of employment that have been affected by mental health concerns is important for getting a more complete understanding of the client.
Current Signs and Symptoms
Although the terms “signs” and “symptoms” are similar and often used synonymously, they are different. The DSM-5 (American Psychiatric Association, 2013) defines “signs” as an objective description of mental health pathology as reported by the examiner, not the client, whereas “symptoms” are described as a subjective manifestation of mental health pathology as reported by the client, not the examiner.
This section is a continuation of the history, but the concerns are discussed in present terms. The information collected is not designed to formulate a diagnosis but rather to connect the buildup of previous concerns to how they remain problematic. Specific information is collected, including examples of the functional impairments currently impacting the client’s mental health.
Past Mental Health Treatment
A history of mental health treatment helps determine what has been helpful and what has not been helpful in the past. Factors such as why treatment was sought, frequency of treatment, type of treatment (e.g., individual, group, inpatient, outpatient), how long the client stayed in treatment, and why services were terminated are each important to assess.
Past Medical Treatment
A medical history can help determine the relationship between the client’s physical concerns and his or her mental health functioning. This information can be helpful in evaluating a possible somatization disorder, conversion symptoms, or exaggeration of symptoms.
Information about a client’s medications is very helpful for several reasons. On a basic level, a list of medications informs the clinician about the current medications the client is receiving. In addition, it is beneficial to inquire about onset of taking mental health medications, their helpfulness, the client’s compliance, any side effects, and any other factors related to treatment. Mental health professionals who are not psychiatrists or others who legally prescribe medications must be careful about making comments or recommendations about medications due to potential malpractice issues.
(p. 61) Legal Issues
A client’s history and current legal problems may provide some insight into his or her behavioral issues, levels of responsibility, and personality issues. The main information needed is the nature and chronicity of the legal problems. For example, there is a significant difference between the legal matters of someone who had a drunken-driving charge 30 years ago versus someone charged with several recent assaults. The emotional and behavioral effects of the clients’ legal circumstance will be certainly different.
A client’s current interests can be a good measure of his or her mental health functioning, motivation, socialization, and any changes in functioning. In addition, incorporating the client’s interests into the treatment plan can lead to more motivation to increase functioning levels.
Many mental health concerns (e.g., agoraphobia, social anxiety, depression, many personality disorders, autism, paranoia) include impairments in social functioning. The client’s relationships with family, friends, coworkers, and authority figures and any changes in them provide much information that is useful for diagnosis and treatment planning. Information about the client’s social supports can be quite helpful in treatment planning.
Substance Use and Abuse
There is a high correlation between mental health and substance abuse. Without evaluating each of these areas, treatment could easily be incomplete. Include information such as both past and current usage, reasons for using, effects of usage, treatment history, relapse history, current craving, and future treatment plans. A description of substance use can be quite helpful in describing how it affects the individual’s ability to cope with stressors, relax, or escape. A decision will have to be made as to whether the chemical dependency or mental health issue will be treated first, or if treatment will take place simultaneously.
Mental Status Exam
The Mental Status Exam (MSE) is one of the most important parts of the initial intake. It consists of clinical observation in areas of the client’s appearance, activity level, speech, attitude toward the examiner, affect/mood, stream of consciousness, and thought content. Typically, the information collected matches the symptoms of the diagnosis.
(p. 62) Affect/Mood
Affective observations refer to what was observed during the interview. Descriptions of the client’s level of affect include the range, appropriateness, mobility, motor activity, predominant mood, and intensity. “Mood” refers to the client’s subjective experience and descriptions of her or his current or usual mental health state. Collecting information about mood refers to asking the client several questions regarding the intensity, frequency, and duration of her or his affective disturbance. This information is used to validate the symptoms in formulating a diagnosis. There is a significant difference in two clients who claim to have the same level of depression, but one has been suicidal and treated for years while the other is experiencing a first bout of less acute depression. The diagnosis, treatment, and prognosis are all different between these two individuals.
All too often personality disorders are overlooked in a diagnostic interview. Concerns in these areas will clearly affect the course of treatment. Personality disorders can be difficult to evaluate, especially when the client is in denial, has a low level of insight, or is not cooperative. However, the same procedures of endorsement of symptoms, observations, collateral information, and related impairments as in other clinical diagnoses are used to formulate a diagnosis.
This section of the interview is a brief evaluation of the client’s level of concentration, orientation, persistency, and academic level. This information can be part of the MSE, but I prefer to list the information separately because of its importance.
Depending on the nature of services, tests are available in areas such as cognition, memory, concentration, development, substance abuse, or the many other reasons that people receive mental health treatment. The information collected is designed to be integrated with the diagnostic interview. If services are being paid for by an insurance company, check the client’s benefits prior to conducting psychological tests, because often a prior authorization for services is required.
(p. 63) Form 12: Treatment Plan
The treatment plan is the blueprint for psychotherapy. It integrates the information collected in the diagnostic assessment and can be revised as more information is collected and as changes take place. The more specific the treatment plan, the more specific the treatment.
There are several formats for writing treatment plans. Many forms have three common elements, which are basically the problem area, goals and objectives, and treatment strategies.
The Problem Area
This section lists specific areas of impairment that will be addressed in mental health treatment. These impairments are to be clearly validated in the diagnostic assessment. Each of these should be treatable within the competencies of the mental health professional or referral sources. Vague terms such as “anxiety” or “depression” should be avoided because they do not clearly define specific functional impairments. Thus, more specific problem areas, which can be attributed to impairments in the client’s life, are appropriate. Listing specific problem areas is clearer than stating vague terms such as “anxiety.” Quantifying specific impairments gives a clear baseline. For example:
Problem Area: Missing three days of work per week due to panic attacks.
Goals and Objectives
Each problem area should have treatment goals and objectives. It is common for treatment plans to have at least three goals. Goals are the overall desired behavioral or emotional effect of treatment objectives that are specific, quantifiable steps to reach the goals. Objectives are often increased to come closer to reach the goal as psychotherapy progresses. For example:
Goal 1: Increase social interactions.
Objectives: By June 10 initiate at least two new social interactions per week; by July 19 initiate at least four new social interactions per week.
Treatment strategies are those that are within the competencies of the practitioner and have been demonstrated as effective for others with similar concerns. Typically, treatment strategies are listed for each goal/objective The type and frequency of treatment is listed. The estimated length of treatment depends on the severity of impairment, the client’s effort and motivation, and clinical judgment. Any of these strategies can be revised. For example:
Treatment Strategies: Cognitive-behavioral therapy, individual, 1/week for 20 weeks
(p. 64) Progress Notes During Treatment Sessions Form 13: Progress Notes
Progress notes are the only evidence of what takes place in a session. They are much more than a brief summary of the session. Just as the treatment plan is the result of the diagnostic assessment, the progress notes (or case notes) are the result of the treatment plan. The most common outlines for progress notes are SOAP (Subjective, Objective, Assessment, Plan) and DAP (Data, Assessment, Plan). The only difference between SOAP and DAP is that the “Subjective” and “Objective” sections in SOAP notes are combined into the “Data” section on the DAP format.
Much helpful information is collected in the data section, including what took place in the session, interventions, observations, test results, documentation of the diagnosis, current impairments, and stressors. Such observations validate the diagnosis but also provide information for treatment strategies for the session. It should be a reflection of the treatment plan.
In the assessment section, once the session is finished the practitioner evaluates the effects of treatment, treatment strategies, and the client’s progress and setbacks. Overall, the section provides information to evaluate regarding outcomes of treatment.
Based on the assessment, a plan is made for future sessions. Perhaps treatment plan strategies, such as mode of therapy, level of objectives, number of session, or intensity of therapy will be revised.
When treatment is no longer taking place, either because the treatment plan goals have been met or for other reasons, there should be a formal discharge from the practice. The following forms are designed to formally discharge the client.
Form 14: Discharge Summary
A discharge summary provides a summary of the effects of therapy. It provides evidence that at the time of termination either services were no longer medically necessary or specific referrals were given, or it provides a notation that the client ended services prematurely. Outcomes measures can be included.
Form 15: Termination Letter
A termination letter is sent to the client when services are no long being used. It is intended to free the practitioner of any further responsibility to the client or for the client’s actions. Such a letter should at a minimum include a statement that the client is no longer a patient of the practice as (p. 65) well as pertinent referrals if appropriate. Additionally, it can serve as a marker of sorts of the transition point out of psychotherapy.
Clinical forms in the practice of mental health can be viewed as either an act of futility or an important part of clinical documentation. Forms provide a structure to organize clinical information in a manner that allows anyone reviewing a client’s records to quickly access information about the client and the course of therapy. The information contained on clinical forms can be especially helpful for the practitioner in reviewing a client’s progress and planning strategies for upcoming sessions. Files with vague documentation make too many demands on the practitioner’s memory from session to session. Plus, when a client changes practitioners, often the only information available is what is contained in the records. Although forms, in themselves, do not serve as documentation, they provide the infrastructure and data necessary for clearly demonstrating the need for services, diagnosis, treatment planning, progress notes, and reason for termination of services.
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Centers for Disease Control. (2016). International Classification of Diseases, Tenth Revision, Clinical Modification. Retrieved from http://www.cdc.gov/nchs/icd/icd10cm.htm.
U.S. Department of Health and Human Services, Office of Civil Rights. (2003). Summary of the HIPAA privacy rule. Retrieved from http://www.hhs.gov/ocr/privacy/.
Wiger, D. E. (2009). The clinical documentation sourcebook: A comprehensive collection of mental health practice forms, handouts, and records (4th ed.). Hoboken, NJ: John Wiley & Sons, Inc.Find this resource:
Wiger, D. E. (2012). The psychotherapy documentation primer (3rd ed.). Hoboken, NJ: John Wiley & Sons, Inc.Find this resource:
Zuckerman, E. L., & Kolmes, K. (2017). The paper office for the digital age (5th ed.). New York, NY: Guilford Press.Find this resource: