This is the fifth post in a series that highlights standardized formats for your clinical notes. The series began here.
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 . . . .
- “What symptoms did my client present today?”
- “How is this impacting their ability to function?”
- “What progress did my client make since his last session?”
- “How does this change my thinking around diagnosis, treatment, planning, and prognosis?”
- “What is my immediate treatment plan and recommendation?”
- “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!