You Can’t Just Shut The Door And Walk Away

Feb
11
2010
by Tamara Suttle

When you get ready to close your private practice, for whatever reason, you can’t just shut the door and walk away. Did you know that?  Attorney Richard S. Leslie has written a thoughtful article in the January 2010 issue of the Avoiding Liability Bulletin.  In it he details some of the following for your consideration when you decide to close up shop:

  • Ask yourself who needs to be notified – clients, former clients, insurance panels, landlords, supervisees, colleagues and business associates, referral sources, and your licensing boards;

    "You Couldn't Have Planned This if You Tried" by Ken Douglas / Today is a Good Day

  • Consider the possible circumstances that might result in you closing your door – retirement, geographical relocation, health emergencies, financial circumstances, your own death, your spouse’ or partner’s death,and other unforeseen circumstances;
  • Your state may dictate certain actions that you must take when you close your practice;
  • Your professional code of ethics and HIPPA will certainly have standards that you must adhere to when closing your practice;
  • How to notify existing clients;
  • Subsequent maintenance, storage, and access to records;
  • How to provide public notice of the closing;
  • When and how to notify former clients;
  • Why you may not want to terminate liability insurance policies when you close your practice;
  • And, in the event of your death or incapacity to handle these things, who does it for you?

Every mental health professional and every professional coach is required to responsibly close their private practice  – regardless of whether their closing is planned or unforeseen.  Whether you’ve been in business for years or you are just now getting started, now is the time to take the steps necessary to prepare for the eventual closure of your practice.

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How To Take Clinical Notes Using Gillman HIPAA Progress Notes

Sep
24
2009
by Tamara Suttle

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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How To Take Clinical Notes Using BASIC SID

Sep
23
2009
by Tamara Suttle

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

Id, Ego, and the Misplaced Monkey by paintMondkey / Daren Higham

"Id, Ego, and the Misplaced Monkey" by paintMondkey / Daren Higham

A third format for clinical note taking is commonly known as BASIC SID.  This is yet another mnemonic.  The letters stand for Behavior, Affect, Sensation, Imagery, Cognition, Spiritual (and Religious), Interpersonal, and Drug (and Biology).

Behavior refers to what you see your client doing and not doing. 

Affect refers to both your client’s mood and congruence with expressing those moods. 

Sensation refers to your client’s awareness of his five senses and includes hallucinations, perceptual illusions, muscular tension or pain, excessive sensitivity to environmental stimuli, and what the client saw and heard. 

Imagery related to your client’s past, present or future in any way includes dreams, fantasies, obsessions, flashbacks and responses to guided imagery. 

Cognitive focuses on your client’s constructed meaning i.e. self talk, mental abilities, personal narrative, beliefs and mental schema.

Spiritual includes your client’s beliefs related to a Supreme Being, affiliation and practices with religious groups, religious resources, conscience and moral development, themes of guilt and forgiveness, creativity, and personal comfort related to ideas of spirituality. 

Interpersonal references your client’s relationships with others, level of social skills, degree of acculturation, and any incidents of social injustices. 

Drug and biological includes your client’s use of chemicals (both illegal and legal), medical compliance and concerns, and any incidents of delirium or dementia.

What I really like about a BASIC SID clinical note is that the acronym provides prompts to help me remember to focus on all areas relevant to my client’s progress.

Tomorrow I will talk to you about taking clinical notes using the Gillman HIPAA Progress Note.

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How To Take Clinical Notes Using DA(R)P

Sep
22
2009
by Tamara Suttle

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

Writing Scathing Notes by JasonRogersFooDogGiraffeBee

"Writing Scathing Notes" by JasonRogersFooDogGiraffeBee

A second format for documenting your clinical work is called DA(R)P notes, sometimes referred to as DAP notes.  These are similar to clinical SOAP notes. 

DA(R)P is a mnemonic that stands for Data, Assessment (and Response), and Plan.

Data, in this format, includes both subective and objective data about the client as well as the therapist’s observations and all content and process notes from the session.

The Assessment and Response includes your clinical impressions, hunches, hypotheses, and rationale for your professional judgment. Progress is also noted here.

Plan refers to your original treatment plan and any response / revisions needed based on your most recent interactions with your client.

This method of clinical note taking is also an acceptable format for your documentation.

Tomorrow I’ll talk to you about BASIC SID notes.

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How To Take Clinical Notes Using SOAP

Sep
21
2009
by Tamara Suttle

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

"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.

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