"Looking Out" by Tyler Neu / Neuski
According to the American Counseling Association’s Code of Ethics, counselors are not required to diagnose a client if they believe that to do so would cause harm to the client. Here is an online article in Counseling Today that addresses some of the ways that diagnosing may be harmful to your client.
"Mental Patient Strapped to Chair" by Curious Expeditions
If you are in need of diagnostic codes 
from the DSM-IV or the ICD-9-CM, check out this handy little website at DoctorCodes.com. By entering the first part of a diagnosis, the site will give you the correct diagnostic code! Quick and sweet! Just make sure you are entering the correct diagnosis to begin with!
Everything you do for your client matters. If and how you choose to diagnose your client matters a lot. Amanda B. wrote in asking if it is OK to routinely give a diagnosis of Adjustment Disorder to her clients if they do not exhibit symptoms warranting a more serious diagnosis. (She was trying to help them get reimbursed by their health insurance companies.)
The short answer is “No it’s not.” As tempting as it may be to slap an Adjustment Disorder diagnosis on to every client who is dealing with normal life transitions, it’s not wise and it’s not OK — clinically, ethically, or legally.
"Worried Woman" by HikingArtist.com / Frits Ahlefeldt-Laurvig
The clinical implication is this . . . by intentionally giving your client the wrong diagnosis, in this case a more serious diagnosis than is truly warranted, you pathologize your client. This is like going to your primary care doctor for a mosquito bite and him diagnosing you with an infection. Mosquito bites happen just like life happens. Misdiagnosing does nothing to empower your client. Nor does it inform her about the real nature of what’s going on or lead her toward useful strategies for managing the transition at hand.
Ethically you’ve failed . . . to provide honest, accurate and useful information to your client if you’ve told her she has something different than what is true. You’ve also set yourself up to provide inaccurate information to others i.e. physicians, lawyers, etch. that may gain access to your records later on.
And, legally, you’re setting yourself up for big trouble. When you choose to list an inaccurate diagnosis on health insurance claims forms and submit them, you have just committed insurance fraud. Should you choose to put the inaccurate diagnosis into your clinical record, you have falsified documents and failed to meet the professional standard of care.
If knowing all of this you are still tempted (perhaps you believe with good intentions) to misdiagnose a client, seek clinical, ethical, and legal consultation.
[Update 10 Dec. 2009 5:54 pm - Of course, mental health professionals are not the only one fudging on diagnoses. Check out The Last Psychiatrist blog post, "How Am I Going To Get Paid If It Isn't Autism?"]
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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:
To obtain this information, Gillman recommends asking yourself these six questions . . . .
Let me know if you try the Gillman HIPAA Progress Note and how it works for you. I’m eager to compare notes!
Tamara G. Suttle, M.Ed., LPC has maintained a private clinical practice since 1991 and founded Private Practice from the Inside Out in 2003. She has spent almost 20 years consulting and teaching marketing strategies to health care professionals like you. You can learn more about her clinical practice at her website.
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