How To Take Clinical Notes Using Gillman HIPAA Progress Notes

Sep
24
2009

This is the fifth post in a series that highlights standardized formats for your clinical notes.  The series began here.

Intense Color Coded Notes by mandiberg

"Intense Color Coded Notes" by mandiberg

I have only recently stumbled across the Gillman HIPAA Progress Note here.  Of the four methods that I have mentioned, this is the only one that has been developed after the introduction of HIPAA. It was developed by Peter D. Gillman, Ph.D. in response to the implementation of HIPAA.   As such, he has taken the extra precaution to intentionally exclude information that is not protected by HIPAA.  I consider that to be a significant improvement over previous iterations of standardized note taking.

I have not yet used this method but plan to try it out.  At first glance, it seems thorough, efficient and equally important, it is fully HIPAA compliant.

If you are not satisfied with the current format of your progress notes, I would encourage you to try this one.  Here’s what you need to include:

  • Time of your session,
  • Treatment and frequency of modalities you provided,
  • A summary that includes, client’s symptoms and functional status, progress, diagnosis, treatment plan and prognosis.

To obtain this information, Gillman recommends asking yourself these six questions . . . .

  1. “What symptoms did my client present today?”
  2. “How is this impacting their ability to function?”
  3. “What progress did my client make since his last session?”
  4. “How does this change my thinking around diagnosis, treatment, planning, and prognosis?”
  5. “What is my immediate treatment plan and recommendation?”
  6. “What is my immediate prognosis?”

Let me know if you try the Gillman HIPAA Progress Note and how it works for you.  I’m eager to compare notes!

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Comments

  1. Hi Tamara,

    Notes is an area I struggle with after moving to private practice. I was able to complete notes with ease when I was working in residential care, but now that model just doesn’t seem to fit. I read your “How to Take Clinical Notes” series and wanted to report back my thoughts on the Gillman HIPAA Progress Notes idea. I tried it out this week and even though I don’t think it’s the answer for me, there were some things I really liked. First of all writing notes with the questions as a guide took less time. Also, the “functional status” question and the “how does this change my diagnostic thinking?” really got me thinking in a different way. Even though I have always looked at treatment planning and diagnosis as living documents, changing and shifting as guided by the client, having the questions helped me relate it to the content of each particular session. Just my thoughts! I will continue my search to finding what fits for me but this one was interesting to try. I learned a lot! Thank you!

    • Hi, Marie! I know exactly what you mean! It’s so difficult when we are first out on our own trying to find the right fits for ourselves! The benefit of having a system for your documentation is that (1) you are training your brain to think systematically and (2) you are less likely to “forget” to include certain aspects of your work. If you find or develop a different way of documenting your work, I hope you’ll drop back in here to share it!

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