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!

  2. Hello,
    I am learning so much from all the conversations and website. As a new private practice owner I am learning so much. I was told by a consultant recently that all progress notes, etc. for clients will need to be electronic by 10/1/2014. Is there a particular software you use that stores all the information and do you scan the data into the computer? Help?
    Thank you so much!

    • Hi, Christina! Welcome to Private Practice from the Inside Out. That’s actually a myth that has been going ’round for a while but the truth is that only hospitals and physicians are going to be required to maintain electronic records. :) I still keep my records the old fashioned way – pen and paper.

  3. Ruth Braunstein says:

    Congratulations Tamara, another well written and informative series. I am interested to try the Gillman ..Progress Notes questions as a guide.

  4. Helen Whitley, LCSW says:

    Hi Tamara,
    I’ve seen your post on various lists and may have emailed with you before. I am in private practice in Woodstock, GA. I came across the article by Dr. Gillman at least a year or so ago, perhaps via the Clinician’s Exchange. It is so different than what I am used to, but I want to use this since it is HIPPA compliant. I have actually tried to reach Dr. Gillman with questions about it to no avail. Feels kind of silly, but I am second-guessing what to put in regards to “frequency of treatment modalities” for example. I guess I would put CBT for the treatment modality furnished, for example but frequency? Do you think it means number of times I think I intervened using CBT in one session? Or does it mean, if I am seeing the client weekly that I would put “1x per week” as the frequency? I would love to see more examples of this note but haven’t been able to find any anywhere!

    • Hi, Helen! Thanks for dropping in today to Private Practice from the Inside Out! And, what is “Clinician’s Exchange?”

      Yes, I do think that “frequency of treatment modalities” is referencing treatment in general because, of course, you are likely to utilize more than oen treatment modality and won’t be likely to know which ones you’ll use during your next session. So . . . How often do you intend to work with this client?

      I hope you’ll tell your colleagues in Georgia about the resources here if you find them helpful!

      • Helen Whitley, LCSW says:

        Hi Tamara,
        Thanks but I am still unclear on that one. Let’s say I am seeing a client weekly. In each and every note it asks you to record type of and frequency of treatment modality provided (in that session) I would assume. So I am saying CBT and whatever other modalities may have come into play in that one session, and then I regards to frequency, am I to record something each time like “provided CBT three times, psychodynamic one time”.. that just doesn’t fit with mental health as we are used to documenting it but is that really what Peter Gillman is saying?

        I honestly have searched high and low for him on the internet and keep getting zero email addresses and old phone numbers. Again I feel silly but I bet a lot of clinicians do.

        Also, he says to document “medication and prescription monitoring”. I have kept that on it’s on sheet in the file, but for purposes of this note, am I to record each medication each time, only psychotropic meds? Only when there are changes to the med and if none, say “NA”…

        Oh, next area is “functional status”. I don’t know whether to say “poor”, good, etc or be more specific about domains of functioning..

        And finally, the fourth ambiguous area is “results of clinical tests”. The only thing I normally have in most client’s files is the Beck scale, Burns Anxiety Scale and YBOCS. Sometimes I have the MAST and or the Copeland ADHD for Adults.. I have the client fill these out between the first and second session usually. Very often I don’t ever ask the client to fill out again. So, right after those are administered if they are considered “testing” I would record those results and then in the subsequent 10-20 session notes, just say “NA”?

        Maybe I am getting nitpicky but if I use these I want to do it right.! Any suggestions appreciated!

        • Helen, this is going to take a little while to answer and because this post is so old, I’m going to take your inquiry to the front of this blog and answer this in a new post. I’ll try to do that within the next few weeks. Hope that works for you!

          • Helen Whitley, LCSW says:

            Yes, that is fine. I have challenged you! I can’t believe I can’t find any examples which would be really helpful. The whole reason I ended up here was I was googling Peter Gillman, PhD and the Gillman progress note. There weren’t many posts and then all contact info I found for him was old.. Thanks for anything you can come up with :).

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