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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Tags: Diagnosis, Documentation, Ethics, Fraud, Standard of Care

If your post-graduate supervision is not all that you had hoped for, there may be a really good reason.  Do you know that clinical supervision is different from administrative supervision?

An administrative supervisor typically operates from a business model rather than a clinical model.  His priority is to make sure that the organization (or her department) runs smoothly. There are local, state, and federal regulations  (like the EEOC guidelines and the Disability Act) that impact his decisions concerning her supervision of you.

Administrative supervisors are often

"In Which Zac Never Realized . . . " by Zac Peckler

what you encounter as a new graduate entering the workforce through an agency, hospital, or school setting. You will recognize an administrative supervisor because he will emphasize paperwork and productivity, managing your caseloads, scheduling, and accountability.

An administrative supervisor must train employees to systematically complete basic paperwork, manage crises, work within systems, and deal with large numbers of clients needing many different things at the same time.  There is much to be learned from an administrative supervisor that will serve you well throughout your career but this is NOT clinical supervision.

If you are frustrated with the quality of the supervision you are receiving, perhaps you assumed that the supervision you would be receiving from your supervisor would be clinical supervision rather than administrative supervision.  Here are some things that you can do to insure that your experience under supervision is all that you want it to be.

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Supervision or Consultation?

Tags: Client Load, Crisis, Documentation, Schedule

When you decide to seek clinical consultation, there are 5 things that you should document in your clinical notes.  They are the 5 W’s:

• When you seek consultation;
• Why you are seeking consultation and why now;
• Who you are seeking consultation from;
• What opinions / information / recommendations you are receiving from that person even if they contradict your own clinical judgment;
• What your final professional opinion / plan is and why you are / are not going to go along with the recommendations received.
  

  "Questions" by Tim O'Brien / Oberazzi

In other words, your clinical rationale all along the way needs to be documented in your notes.  Why?  To protect both you and your client.

Should you end up in a malpractice suit (which is quite possible), your proper documentation will assist you in explaining your thought process concerning your work with your client.  Likewise, should anything happen to suddenly prevent you from continuing to work with your client, your general direction of treatment can more likely continue seemlessly because you have taken the time to thoroughly document your clinical rationale and intent.

Tags: Consultation, Documentation

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

"Soap Carving" by Narisa Spaulding

Probably the most common form for standardizing your clinical notes is SOAP notes.  It’s likely that you learned how to document in this standardized form early on in your training as a mental health provider and you may have continued to use this format up until now.  SOAP is a mnemonic that stands for Subjective, Objective, Assessment, and Plan.

In this format, Subjective includes only the client’s subjective information.  Often this looks like a summary statement or direct quote from the client.

The Objective portion of your clinical note is observable data or information that coincides with the subjective statement.  Typically this includes the client’s body language and affect.

The Assessment is your professional and clinical judgment based on the aforementioned Subjective and Objective statements.

The Plan includes your intentions for future clinical work, any homework that was given, any referrals / interventions made, and any follow up needed or completed.

Many agencies and organizations use SOAP notes as their standard format for note taking.   Although it can be awkward and does not always easily permit the inclusion of data that you might feel is pertinent, SOAP continues to be a commonly accepted format for documentation of clinical notes.

Tomorrow I’ll talk to you about DA(R)P notes.

Tags: Assessment, Documentation, Follow Up, Homework, SOAP Note, Treatment Plan

On Monday, Brenda Bomgardner, a student intern at Regis University, wrote in asking for efficient ways to record her clinical notes.  This is the first of five posts to help you sort through your choices for clinical note taking.

"Leave Me Alone - I Know What I'm Doing" provided by foundphotoslj

You can be reasonably confident that  if you are working in an agency, the content and format for your clinical notes are already stipulated.  However, for those of you entering private practice, you have more leeway in deciding what your client notes, often called “progress notes“,  will look like.

All mental health disciplines require documentation of your clinical work.  Although the required content for that documentation varies from discipline to discipline and from jurisdiction to jurisdiction, there are general categories of information that are required for you to keep in your records. These categories typically include contact information, your client’s presenting problem, your assessment, treatment and plan.

In addition to free form notes, there are at least four common ways to standardize and record this information.  They are:

• SOAP Notes,
• DA(R)P Notes,
• BASIC SID Notes,
• and Gillman HIPAA Progress Notes.

Next week, I’ll share with you how each of these differs.  Then you can decide how best to keep your own clinical notes.

Do you know of other formats that you like to use?  If so, please share them with us here so that we may all learn from you!

Tags: Assessment, BASIC SID Note, DA(R)P Note, Documentation, Gillman HIPAA Progress Note, Presenting Problem, SOAP Note, Treatment Plan