Where Law & Ethics Meet Efficiency · The Progress Note: Where Law & Ethics Meet Efficiency 03/25/2020 Presented by Elizabeth "Beth" Irias, MS, LMFT 1 THE PROGRESS NOTE: Where Law

The Progress Note: Where Law & Ethics Meet Efficiency

03/25/2020

Presented by Elizabeth "Beth" Irias, MS, LMFT 1

T H E P R O G R E S S N O T E :W h e r e L a w & E t h i c s M e e t E f f i c i e n c y

Welcome, your facilitator will be: Samson Teklemariam, LPC, CPTM

• Director of Training and Professional Development for NAADAC

• NAADAC, the Association for Addiction Professionals

• www.naadac.org/education• [email protected]

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www.naadac.org/webinars

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Using GoToWebinar(Live Participants Only)

Control Panel

Asking Questions

Audio (phone preferred)

Polling Questions

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Elizabeth ‘Beth’ Irias, LMFT

Not an attorney!

The information provided herein does not, and is not intended to, constitute legal advice. All

information and content is for general informational purposes only.

• Utilization Review & Clinical Documentation Consultant

• Private Practice Therapist

• Adjunct Graduate Psychology professor at Pepperdine University

President & Founder of Clearly Clinical, a low-cost national podcast Continuing

Education Company approved by

NAADAC Webinar Presenter

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Webinar Learning Objectives

List three legal and ethical implications of inadequate clinical documentation practices

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Identify five important components of quality clinical documentation as they relate to Best Practice

Provide a general definition of the term ‘Medical Necessity’ as related to Clinical Documentation

Polling Question

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Have you been told by someone (a professor, a supervisor, a boss, a colleague) to keep your progress notes short and vague?

A.Yes, I’ve been told that!

B.Nope, I’ve never been told that.

The Way I See It● My ‘why’

● Care access issues

● The ‘Medical Model’

● Making it stick

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Underlying Clinical Records

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WHOWHAT

WHEREWHY

WHEN

Records: Who Are They For?

A misnomer: “Client chart”

*Note: Make sure to know your state’s requirements relating to the documentation of sensitive information

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Big Picture Thinking

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Improved Utilization Review Outcomes (if care is managed by

third parties)

Improved Utilization Review Outcomes (if care is managed by

third parties)

Improved Client CareImproved

Client Care

More Financial Stability, Including Liability Reduction

More Financial Stability, Including Liability Reduction

Quality Clinical DocumentationQuality Clinical Documentation

↙ ↓ ↘

↘ ↓ ↙

Increased Clinical Reflection and

Responsiveness

Increased Clinical Reflection and

Responsiveness

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You Can’t Say I Didn’t Warn You

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NAADAC Code of Ethics, Section I-19

“Addiction Professionals and other Service Providers shall create, maintain, protect, and store documentation required per federal and state laws and rules, and organizational policies.”

NAADAC, the Association for Addiction Professionals (2016). NAADAC/NCC AP Code of Ethics. Alexandria, VA: NAADAC. Retrieved from: https://www.naadac.org/assets/2416/naadac-code-of-ethics.pdf

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American Psychological Association Record Keeping Guidelines

“Psychologists keep records in order to:

• Provide good care• Assist collaborating professionals• Ensure continuity of professional services• Provide for supervision or training• Provide documentation required for

reimbursement or required administratively under contracts or laws

• Document any decision making, especially in high-risk situations

• Allow the psychologist to effectively answer a legal or regulatory complaint”

American Psychological Association. (2007). Record keeping guidelines. The American Psychologist, 62(9), 993-1004.

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American Counseling AssociationCode of Ethics, Section A.1.b.

“Counselors include sufficient and timely documentation to facilitate the delivery and continuity of services. Counselors take reasonable steps to ensure that documentation accurately reflects client progress and services provided.”

American Counseling Association. (2014). ACA code of ethics. Retrieved from http://www.counseling.org/docs/ethics/2014-aca-code-of-ethics.pdf.

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American Association for Marriage and Family Therapy Code of Ethics, Section 3.5

“Marriage and family therapists maintain accurate and

adequate clinical and financial records in accordance with

applicable law.”

Aamft.org. (2017). Code of Ethics. [online] Available at: http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx [Accessed 11 Mar. 2019].

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National Association of Social Workers Code of Ethics, Section 3.04

“(a) Social workers should take reasonable steps to ensure that documentation in electronic and paper records is accurate and reflects the services provided.

(b) Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future…”

Workers, N. A. (2008). NASW Code of Ethics (Guide to the Everyday Professional Conduct of Social Workers). Washington, DC: NASW.

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State Laws and State Ethical CodesInquire with your professional association for guidance about your state’s specific ethical codes and laws relating to clinical documentation

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An Example of a Documentation-Related State Law

California Health & Safety Code §123130

“… [A] summary must contain the following information if applicable:

• Chief complaint(s) including pertinent history

• Findings from consultations and referrals to other health care providers

• Diagnosis• Treatment plan • Progress of the treatment• Prognosis including significant

continuing problems or conditions• Pertinent reports of diagnostic tests• Discharge summaries...”

https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=123130 .Added by Stats. 1995, Ch. 415, Sec. 8. Effective January 1, 1996.

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The Joint Commission’s Take

From A Practical Guide to Clinical Documentation in Behavioral Health Care (1997):

“Today, the quality and content of the client record may well determine whether treatment is deemed appropriate and level of care are justified and reimburseable.”

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Consequences of Inadequate Documentation

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Auditing Impact“If it’s not in the chart, then it

didn’t happen.”

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Utilization Review & Disability Benefits

Our records can impact a client’s ability to receive things like

insurance authorizations and disability coverage.

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ReputationWhat does your current

documentation say about the quality of your work?

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The ‘F’ Word “Health care fraud is a type of white-collar crime that involves

the filing of dishonest health care claims in order to turn a profit.”

NOTE: Fraud does not have to be intentional to be a crime

Cornell Law School, Legal Information Institute. (n.d). Retrieved from https://www.law.cornell.edu/wex/healthcare_fraud

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Fraud Red Flags

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Copied-and-pasted phrases

or sections

Frequent revisions to

entries

Missing entries

Service overlap

Inaccurate charting

Unforeseen Circumstances What happens if you abruptly

leave your practice and your records are disorganized?

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How Good Is Your Memory?

Record Retention in California, for example:

“The Seven-Year Rule”

BUT: A complaint can be filed with the CA Board of Behavioral Sciences for 10 years after the

service occurred

Ofer, Z. (n.d.) California Law On Record Keeping and Records Retention.Retrieved from https://www.zurinstitute.com/recording-keeping-ca/

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A Board Complaint A board complaint can

sometimes start with one thing, and end someplace else

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Polling Question

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Can behavioral health and addiction providers go to jail relating to clinical documentation oversights?

A.Yes, in some cases.

B.No, that pretty much can’t happen.

Legal LiabilityWinton, R. & Knoll, C. (2018, September 13). Charges upheld against L.A. social workers in death of 8-year-old Gabriel Fernandez Los Angeles Times.. Retrieved from https://www.latimes.com/local/lanow/la-me-ln-gabriel-fernandez-social-workers-abuse-20180913-story.html.

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FEAR NOT!There’s a lot you can do to get your records in tip-top shape!

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The Term ‘Medical Necessity’

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The Term ItselfFrom Treatment Planning for Person Centered Care by Adams and Grieder (2014):

“Simply stated, the demonstration of Medical Necessity requires that there is a legitimate clinical need and that services provided are an appropriate response.”

Adams, N., & Grieder, D. (2014). Treatment planning for person-centered care: shared decision making for whole health. London: BAcademic Press/Elsevier.

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Why Medical Necessity Matters Imagine a doctor performing a

procedure that wasn’t medically-necessary.

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The Clinical CycleDo all of these pieces continually fit together?

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Diagnosis Assessment

Treatment Progress

Plan Notes

Most third-party payers will only pay for services if they are the following:

Indicated

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Adams, N., & Grieder, D. (2014). Treatment planning for person-centered care: shared decision making for whole health. London: BAcademic

Press/Elsevier.

Appropriate

Efficacious

Effective

Efficient

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From The Joint Commission’s 2018 Documentation Guide

“If it’s done effectively, documentation support and guides, justifies and confirms: It communicates.”

Crittenden, P. (Ed.). (2018). Documentation of care, treatment, or services in behavioral health care. Oak Brook, IL: Joint Comm. Resources.

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California Welfare And Institutions Code §14059.5

“[A] service is ‘medically necessary’ or a ‘medical

necessity’ when it is reasonable and necessary to protect life, to

prevent significant illness or significant disability, or to

alleviate severe pain.”

Code Section. (n.d.). Retrieved June 01, 2017, from http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=WIC§ionNum=14059.5

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Polling Question

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Do you work with insurance companies? (I.e.: Do you or your company receive reimbursement from insurance providers for sessions?)

A.Yes, I do.

B.No, I don’t.

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Insurance Company Definitions

If you accept insurance, you need to know the Medical Necessity Criteria and Level of Care guidelines

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Where Medical Necessity Needs To Be...

In your:

● Assessment● Treatment Plan● Progress Notes● Discharge Plan● Case Notes● Medical/Nursing Notes

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Medical Necessity Recap

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Adams, N., & Grieder, D. (2014). Treatment planning for person-centered care: shared decision making for whole health. London: BAcademic Press/Elsevier.

There is a legitimate clinical need

Services provided are an appropriate response

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Writing Progress Notes

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The Safety F.I.R.S.T. Mnemonic©

What really needs to be in your notes

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Safety F = Functional Impairment

I = Interventions

R = Response

S = Symptoms

T = Therapeutic Interpretation48© Elizabeth Irias, 2018

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SAFETY©

Have I documented the critical safety/risk factors?

(If there are any… maybe there aren’t!)

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F= Functional Impairment ©

How does the individual’s condition or situation impact his/her/their ability to function in important domains, like work, school, home, etc.?

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An Example: Chuck

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An Example: Chuck

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An Example: Me

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And Again: Chuck

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And Again:Me

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I= Interventions ©

What treatment intervention did you use, and what was the clinical reasoning behind it?

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Intervention Example ©

“Therapist encouraged the client to identify the pros and cons of switching majors in

college.”

Why?

“IN ORDER TO… (insert reason)”

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The Power Of ‘In Order To’ ©

Let’s go back to…

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“How you doin’?”

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R= Response ©

How did the client respond to you and your interventions?

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S= Symptoms ©

Document both the symptoms you observe and the reported symptoms

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T= Therapeutic Interpretation ©

This may include:

• Treatment compliance/lack of compliance

• Clinical impressions • Progress• Relapse potential • Prognosis• Exercise of clinical judgment• Plan

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The Clinical “Fancy Hat”

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Safety F = Functional Impairment

I = Interventions

R = Response

S = Symptoms

T = Therapeutic Interpretation66© Elizabeth Irias, 2018

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The ‘So What’ Challenge

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The Joint Commission’s ‘So What’ Questioning

“... So what does all this data mean, doctor? So what is my condition? So what are my problems? So what should I do to resolve the problems I have, and where do I start? So what can you or others do to help me? So what can I do to help myself? So what should I look for and watch to see that I am progressing?”

J. (Ed.). (1997). A Practical Guide to Clinical Documentation in Behavioral Care. Joint Commission on Accreditation of Healthcare Organizations. Also, http://www.carf.org/Accreditation/QualityStandards/ Health

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TJC Gets It!“It is not that clinicians fail to complete evaluations or to identify the ‘so what’ questions; they merely do not write them proficiently and sometimes do not write them at all.”

J. (Ed.). (1997). A Practical Guide to Clinical Documentation in Behavioral Health Care. Joint Commission on Accreditation of Healthcare Organizations. Also, http://www.carf.org/Accreditation/QualityStandards/

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My Play On ‘So What Questioning’

“Client reports that her boss is becoming increasingly more frustrated with her absences, and she was written up yesterday.”

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��

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So what?

So what?

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More stress, worse insomnia.

More alcohol use.

More work absences.

So what?

So what?

She may lose her job.

So what?

She may lose her housing.

What This Note Needs To Say

“Client reports that her boss is becoming increasingly more frustrated with her absences, and she was written up

yesterday; this stress appears to have been contributing to her increase in alcohol use, in a circular manner. Client’s job appears to

be at risk (as well as her housing should she lose her job), due to her mental health

symptoms and substance use.”

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Polling Question

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How long do you spend writing an average progress note (not a crisis session note)?

A.Fewer than three minutes

B.Three to 10 minutes

C.10 to 20 minutes

D.Longer than 20 minutes

How Long It Should Take

With some practice and patience, writing a sound

progress note should take a few minutes, and no more

than 10 minutes.

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What To Expect

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How Much To Write

Rule of Thumb:

*Write at least one intervention AND one

response for every 10 or 15 minutes of session

*Not including crisis sessions!

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A Hotly-Contested Topic

Duplicate Content

= Audit Red Flag

Not inherently and always bad, but copy/paste must be used

carefully, only when appropriate, and only when

specifically applicable.

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Other Best Practice Points to Remember

• Complete a note with each service

• Complete all note fields• Scope of practice• Use clinical and neutral

language when describing clients and their behaviors

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How To Avoid Novel-Writing:

Six Questions To Ask Yourself © Elizabeth Irias, 2018

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Question OneHave I documented the critical

safety/risk factors?©

(If there are any… maybe there aren’t!)

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Question TwoIf I had 30 seconds in a case

conference to present this session, what would I say?©

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Question ThreeWhy do I think the client needs

this treatment?©

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Question FourIs this a summary of the session,

or is it a play-by-play?©

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Question FiveIs this sentence generally

relevant to the gist of the note?©

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Question SixDoes the client’s actual quote

explain this better than my clinical interpretation (ie-

‘psychobabble’)?©

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Wrap Up

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You Did It!We discussed:

• Medical Necessity

• Common ways clinicians put themselves at risk with documentation practices

• Best Practice in clinical documentation

• Strategies for effective and efficient documentation

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Now, put theory into practice, and go get

‘em!

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Contact Information

Elizabeth ‘Beth’ Irias, LMFT

[email protected]

ClearlyClinical.com

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www.naadac.org/progress-note-efficiency-webinar

UPCOMING WEBINARS

Social Media and Ethical Dilemmas for

March 27h, 2020

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Documents

Where Law & Ethics Meet Efficiency · The Progress Note: Where Law & Ethics Meet Efficiency 03/25/2020 Presented by Elizabeth "Beth" Irias, MS, LMFT 1 THE PROGRESS NOTE: Where Law