Noteworthy Documentation

Noteworthy Documentation

An interview with Dr. Ben Caldwell, LMFT about some basic documentation information as well as updates relevant to the 21st Century Cures Act. Curt and Katie talk with Ben about what to consider when writing your notes including what to include and what should not be included. We look at who can see your progress notes as well as other considerations related to records requests and confidentiality.      

It’s time to reimagine therapy and what it means to be a therapist. To support you as a whole person and a therapist, your hosts, Curt Widhalm and Katie Vernoy talk about how to approach the role of therapist in the modern age.

Interview with Dr. Ben Caldwell, LMFT

Dr. Benjamin Caldwell, PsyD is a California Licensed Marriage and Family Therapist (#42723) and the Education and Director for SimplePractice Learning. He currently serves as adjunct faculty for California State University Northridge in Los Angeles. He has taught at the graduate level for more than 15 years, primarily in Law and Ethics, and has written and trained extensively on ethical applications in mental health care. In addition to serving a three-year term on the AAMFT Ethics Committee, Dr. Caldwell served as the Chair of the Legislative and Advocacy Committee for AAMFT-California for 10 years. He served as Editor for the Users Guide to the 2015 AAMFT Code of Ethics and is the author for several books, including Saving Psychotherapy and Basics of California Law for LMFTS, LPCCs, and LCSWs.

In this episode we talk about:

• Documentation as our favorite thing ever
• Excitement about Ben breaking the record on number of interviews on this podcast
• What needs to go into your documentation
• Accurate, adequate, and timely
• Standard of care
• How much information to put into your notes
• Who is the audience for your documentation
• Who might request records
• The importance documentation in continuity of care
• Where to put client quotes
• The difference between progress and process or psychotherapy notes
• What can be subpoenaed (including psychotherapy notes)
• How much information you include based on what is advisable to protect self
• The benefit of doing documentation for yourself as well as for treatment efficacy
• The 21st Century Cures Act – Open Notes (deadline now extended through April 2021)
• Optional certification process that requires clients to have access to all the information in their chart without charging them)
• Most mental health providers have no changes required from this change
• Most private practice EHRs are not on these systems
• Hospitals may have this requirement, but individual practitioners are not responsible for the mechanism to provide documentation to clients
• How to make sure you’re ready for clients to see your documentation
• The communication is going on for people who are required to comply with this open notes mandate, including how to access information and who to contact with questions
• In most states, clients have a fundamental right to request their records
• Confidentiality and access to records for family members, especially parents of minor children
• Conversations to have at the beginning of treatment in these situations regarding what will be included in the chart (and what will not be put into the chart)
• What not to include in your chart (specifically written reports from child abuse reports)
• A debate of who owns the record – who can see them is different from who owns them