Most of the requirements around progress notes come from regulators and payors.
I have always been taught, and practiced, according to the following ideas which are based on the "medical model";An assessment leads to a diagnosis.A diagnosis leads to a treatment plan to minimize, if not eliminate symptoms and increase functioning.The treatment plan is composed of goals, and treatment interventions.The "provider notes" are labeled "progress" notes to describe progress toward the achievement of treatment goals.The treatment plan is adjusted according to the "progress made."Conclusions:Progress notes make no sense without a treatment plan specifying treatment goals.The progress notes make little sense unless they detail treatment interventions and level of achievement to goals.Regulators often have additional requirements like;Treatment summaries every 90 days.Discharge summaries detailing the achievement of treatment plan goals at the conclusion of "treatment"In many settings, these assessments, treatment plans, and summaries must be co-signed by a supervisor and/or medical director.In New York State, the Office of Mental Health, and Office of Alcoholism and Substance Abuse Services periodically do surprise visits to audit records. The agency's operating certificate depends on medical records compliance. Also State Medicaid funding is tied to required medical record documentation, If records are out of compliance, agencies can be assessed "pay backs" and agencies have to return sometimes millions if not hundreds of thousands of dollars of Medicaid money paid for services rendered but not recorded in the specified formats.I have been through these audits and in the 90s they were draconian. This has led to staff time being skewed to medical record documentation for regulatory compliance rather than patient care. Many counselors dream of escaping this system to private practice to be liberated from enslavement to such systems.I, currently, have 4 medical requests now on my desk from Ciox because Medicare is auditing Medical Option plans looking for Medicare fraud. It is interesting how the accountants and regulators have such a big impact on health care delivery to the extent that some physicians say that an equivalent amount of time and effort is spent on documentation rather than patient care. The same complaint is made by mental health professionals captured by these publicly funded agencies with all their regulatory requirements.Enter the Electronic Health Record which promises to make these documentation requirements more efficient and effective. It's utter nonsense. I got a 12 page fax yesterday of a treatment summary for a partial hospitalization episode of a patient being referred to me for outpatient care. The only information the least bit helpful was the demographic information and diagnosis. All the rest were check boxes and fill in the blank kind of data reminding me of Mad Libs party games that has no context for living, breathing, sentient human being.This kind of stuff makes me very sad at the end of my career. The robots have taken over and have convinced us to use these systems of care of human beings. Makes me cry. The point of these systems is not good patient care but, as always, money.
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