Overview | Clinical Scenarios | Additional Tips | References

By Charles D. Cash, JD, LLM

OVERVIEW

Definition

Record keeping is the process of collecting, organizing, and maintaining information gleaned in the usual course of treating patients. The resulting treatment record has three essential purposes:

• To support good clinical care;
• To defend against complaints and show compliance with legal requirements;
• To substantiate billing and show compliance with payer guidelines. (1)

General Principles

• Most states have statutes and regulations governing the creation, maintenance, and retention of treatment records. Even when such requirements are absent, it is the standard of care to maintain a record for each patient. 
• Other sources provide evidence of the appropriate standard for record keeping:
  • Position papers, guidance documents, etc., from regulatory or administrative agencies, e.g., state medical licensing board
  • Authoritative treatment guidelines 
  • Position documents, policies, guidance documents of major professional organizations
  • Medical staff bylaws
  • Facility policies and procedures
  • Standards of accreditation and quality assurance organizations

• Third-party payers also may impose record-keeping requirements. 

CLINICAL SCENARIOS 

Scenario #1: A patient offers that she would like to divulge extremely sensitive information to the psychiatrist but does not want that information recorded in the treatment record. How should the provider approach this situation? 

• In this situation, the provider should not promise that relevant information revealed by the patient will not be noted in the record. 
• The confidentiality protections afforded treatment records should be discussed with the patient. 

Scenario #2: A family member offers voluminous documentation about a patient’s past treatment and social life. Must the provider include all of this documentation in the patient’s treatment record?

• If information is clinically relevant to the patient’s treatment, it should be included in the record. 
• The provider may exercise professional judgment in choosing what material should be incorporated into the record. 
• Relevant past treatment records obtained and reviewed by the provider should be incorporated into the patient’s current treatment record. 
• Details about a patient’s past treatment and social life that are not relevant to current treatment may be excluded. 

Scenario #3: A patient reveals that he is having an affair with the Governor of the state. How should the provider document this revelation? 

• The provider can document discretely. 
• The fact that a patient is having an affair may be clinically relevant, but not the identity of his or her paramour. 

ADDITIONAL TIPS

1. Uncertainty about the content of the treatment record can be a source of angst. 
   1. Consider using a documentation methodology such as SOAP notes. 
   2. Each significant patient interaction should be documented. Document attempts, successful and unsuccessful, to contact patients.
   3. Include, at a minimum: 
      1. Dates (and length) of service;
      2. Pertinent history;
      3. Initial assessment, diagnosis, and subsequent re-assessments of the patient’s needs;
      4. Any signed informed consents for treatment and authorizations for release of information, including releases to third-party payers;
      5. Names, addresses, and telephone numbers of the patient and designated others;
      6. Consultations with other health care providers;
      7. Reports from psychological testing, physical examinations, laboratory data, etc.;
      8. What treatment options/actions were considered, what options/actions were chosen and why, and what options/actions were rejected and why;
      9. Prescriptions of medications, adjustments of dosage, etc.;
      10. Progress notes or other documentation that reflects a patient’s reaction to treatment or the need to change treatment;
      11. Documentation of the termination process;
      12. A discharge summary (if relevant), including patient’s status relative to goal achievement, prognosis, and future treatment considerations; and
      13. Copies of relevant correspondence concerning the patient.
2. In determining what should go into the treatment record, it may be helpful consider the intended audience – a subsequent treatment provider. A subsequent treatment provider should be able to read the treatment record and understand what happened in treatment and the reasoning behind the current provider’s clinical choices.
3. While the treatment record serves multiple purposes, it is primarily a clinical document. If a treatment record fulfills its clinical purpose, it likely will be sufficient for defensive and billing purposes.  
4. Documentation of important clinical choices, such as admission or discharge decisions, major changes to the treatment plan, or changes in observation level, should include the provider’s reasoning behind the choice. Additional discussion of the Professional Judgment Rule (audio file). 
   1. Should the record be needed for defensive purposes, great deference is typically shown to providers if the reasoning behind their clinical choices can be understood through documentation in the record. 
   2. A well-documented chart prevents plaintiff expert witnesses from making up their own story about what happened in treatment. 
5. Treatment record entries should be made timely, in as close proximity to the patient encounter as possible. 
6. It may be helpful to establish separate sections within a record for clinical documentation, correspondence, records from other providers and institutions, and billing information.
7. “No SI/HI” does not give much information about patients’ actual risk assessments. Consider fleshing out such an entry. 
8. Use only accepted methods for correcting mistakes. 
9. Safeguard records – both paper and electronic. 
10. Legal and risk management consultations should not be documented in the patient’s record. 

POST-EVENT DOCUMENTATION

Should a bad outcome occur, such as a patient suicide, no treatment record entries should be created without consulting legal counsel or risk management. Post-event documentation can jeopardize the evidentiary value of the treatment record. Additional discussion of post-event documentation (audio file).

PSYCHOTHERAPY NOTES (2)

1. The only special protection that the Health Insurance Portability and Accountability Act (HIPAA) affords mental health information is the option (not requirement) to keep psychotherapy notes physically segregated from the rest of the treatment record. A separate authorization is required for the release of psychotherapy notes maintained in this fashion. 
2. Psychotherapy notes are considered not useful for treatment, payment, or healthcare operations, so would not need to be routinely released for those purposes, such as when a third-party payer requests a record copy for audit purposes. 
3. Psychotherapy notes are discoverable in litigation and patients may request that copies of psychotherapy notes be released to others. 
4. The additional protection afforded psychotherapy notes is minimal, so keeping them physically segregated in the treatment record may not be worth the effort. 
5. States may have their own regulations addressing psychotherapy and other notes. 

ELECTRONIC HEALTH RECORDS

1. Thoroughly understand their operation.
2. Make sure that documentation accurately reflects the patient encounter.
3. Avoid using templates, check boxes, fields that auto-populate, and the copy & paste function. 
4. Back up electronic records.

SIGNATURES (3)

1. Providers may be asked to sign forms related to patients they have not seen. 
2. Provider signatures should be annotated so that it is clear what the signature means. 

RETAINING AND DESTROYING RECORDS

1. Statutory and regulatory retention period requirements typically are for continuity of care purposes and may be inadequate to protect providers from professional liability exposures. 
2. If indefinite retention is not possible, consider a retention period at least 10 years from the date of last treatment for adult patients and 28 years from the date of last treatment for minor patients. 
3. If records are to be destroyed, they should be destroyed completely. 
4. Keep a log of the records destroyed. 
5. Do not destroy records that have been requested by another party or are involved in continuing litigation, investigation, or audit. 

REFERENCES 

1. Professional Risk Management Services. Documentation. Rx for Risk 2017; 25(2). www.prms.com/media/1662/rx_for_risk_v25_issue2_digital.pdf. 
2. U.S. Department of Health and Human Services, Office for Civil Rights. Does HIPAA provide extra protections for mental health information compared with other health information? www.hhs.gov/hipaa/for-professionals/faq/2088/does-hipaa-provide-extra-protections-mental-health-information-compared-other-health.html. 
3. American Psychiatric Association. Guidelines Regarding Psychiatrists’ Signatures. APA Resource Document 890002, June 23, 1989.

Additional Reading

1. Mossman, D. Tips to make documentation easier, faster, and more satisfying. Current Psychiatry. 2008;7(2):80-86. Accessed at: www.mdedge.com/psychiatry/article/63012/tips-make-documentation-easier-faster-and-more-satisfying. 
2. Bastiaens, L. Better psychiatric documentation: From SOAP to PROMISE. Current Psychiatry. 2013;12(3):50-51. Accessed at: www.mdedge.com/psychiatry/article/65042/practice-management/better-psychiatric-documentation-soap-promise. 
3. Vanderpool, D. EHR Documentation: How to Keep Your Patients Safe, Keep Your Hard-Earned Money, and Stay Out of Court. Innovations in Clinical Neuroscience. 2015;12(7–8):34–38. Accessed at: https://innovationscns.com/ehr-documentation-how-to-keep-your-patients-safe-keep-your-hard-earned-money-and-stay-out-of-court/.