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

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!

Tags: Change, Clinical Note, Diagnosis, Gillman HIPAA Progress Note, HIPAA, Modality, Prognosis, Progress, Recommendation, Symptom, Treatment Plan

I received a call this week from a counselor who has recently moved into Colorado.  She asked if I could provide clinical supervision for her post-graduate work.  As we explored that possibility, the conversation turned to her previous experiences with clinical supervision and they were less than ideal.

If you, too, find yourself tempted to settle for a less than ideal supervisor, you are in need of a supervision rescue. Here are some ideas to consider. . . .

There is NO correlation between being a good therapist and being a good clinical supervisor.

Although the knowledge bases overlap, they require decidedly different skill sets.  Teaching, training, and monitoring are necessary for clinical supervision but are not the tasks of a counselor. Thus, the trend to require supervisors to have formal training in supervision.

Poppy Love . . . . #4 -- squaRED by onkel wart / Thomas Lieser

Mental health professionals are trained to initiate and facilitate difficult conversations.

This may be the perfect opportunity for you to discuss and re-negotiate your supervision with your current supervisor.  Perhaps she was unaware of your interest in clinical supervision and is willing and able to change how she supervises you ; or, perhaps she is not skilled in clinical supervision and can help facilitate a transfer for you to work under someone different who provides clinical supervision.  

Be clear about what you want / expect / need and ask for it.

Some therapists find that it works better to get clinical supervision from someone other than their immediate supervisor at work.

What you may not have realized is that if your boss may be functioning as  your administrative supervisor AND your clinical supervisor.  If so, at least some of the time, it is likely that she will have conflicting/dual roles.

You can’t always speak openly about mistakes that you’ve made with someone who has the authority / responsibility to fire you.

Many organizations are open to contracting with an independent  licensed mental health professional to provide weekly clinical supervision to their employees as an employee benefit.

This supervision may be provided to a small group, to you individually, or in some combination of the two. An organization can contract for this supervision at a much lower fee than if you seek out private supervision on your own.  

If your work site does not currently offer this type of supervision, perhaps it’s time to do a little reconnaissance work and then pitch the idea to them.

Related Posts

Clinical Supervision and Money Gouging

10 Questions You Must Ask Your Potential Supervisor

9 Steps You Can Take to Insure a Great Supervisory Experience

Tags: Change, Contract, Dual Roles, Mistakes, Supervision

Even if you are doing many things “right,” you can still end up destroying your private practice. Here’s the 5 top ways you can blow it up fast:

# 5 – Don’t change things up.
Keep doing the same old things you used to do when you started in the business 20 years ago. Be predictable i.e. boring. Keep working with the same old issues (and only those same old issues) that you’ve always worked with. Don’t develop new bodies of work, new skills, or new interests. Allow your work and your practice to become dated and irrelevant. It works every time.

Caution! Caution!

# 4 – Don’t ask your clients.
Whatever you do, do not survey or poll your clients. Don’t ask for their feedback about anything . . . your office location, the way they are greeted at the front desk, your billing / fee collection process, your clinical effectiveness, or their thoughts about your work after they terminate. And, should your clients volunteer such feedback, be sure to argue, justify, or dispute it. Whatever you do, make sure you do not actually consider it and make appropriate changes (see comments above).

# 3 – Don’t ask for referrals.
Don’t explain that you are expanding your practice; don’t tell friends and family that you have a few extra time slots to fill; and, don’t tell clients that your business depends on referrals from satisfied customers. Better yet, tell everyone you know that you have a one month waiting list and are not looking for new clients.

# 2 – Don’t brand yourself.
Branding is for businesses that want to present a clear, succinct and memorable message about who they are and what they represent. By not branding you and your private practice, you can ensure that your business becomes forgettable, at best and, at worst, becomes confused with too many / unprofessional images and messages. To kill your practice, I highly recommend avoiding all tendencies toward branding.

# 1 – Don’t niche your practice.
Most importantly, try to be everything to everyone. Be a generalist. Do everything OK. Work with everyone all right. Refuse to specialize in anything and become forgettable fast.

Why isn’t your private practice surviving?

Tags: Brand, Change, Feedback, Niche, Survey