Posted by gardenergirl on January 30, 2005, at 18:26:18
In reply to Question for you » gardenergirl, posted by mair on January 30, 2005, at 14:10:50
Well, I suppose it depends on the requirements of the site and/or the third party payors. Usually there is a note documenting the initial session, which may have some detail about history or it may not. Again, this is T's preference and also depends on the site. Usually there is some documentation of each session. Some T's simply write that the session occured. Others write in general about what was covered. Some write at length about process and content. There is a distinction between notes documenting that service occured and psychotherapy notes. Psychotherapy notes (what has more detail, and could include T's thoughts, speculations, reactions, etc. or could just rehash the session) are in general more protected for privacy. HIPAA says that insurers cannot access psychotherapy notes. You might find a treatment plan. Often, this is shared with the client and may even be signed by the client. This might include a diagnosis or at least something describing the problem, relevant goals, treatment interventions, and progress signs. And finally, after termination, there should be a termination summary. This is pretty much what it sounds like. It summarizes the presenting problem, course of treatment, any unusual events, progress or lack of, and disposition.
All of this may be very general or very detailed. The best I could suggest would be to ask your T about what they document. Frankly, I don't know what my own T does! I did have a discussion about how they are protected, since they don't fall under HIPAA but rather some other protection related to educational records.
I know I try (don't always succeed) to make sure that whatever I write in the note is not soemthing that I would be concerned about the client reading. Because they do have a right to read them, at least in my state.
Hope this helps.
gg
poster:gardenergirl
thread:443118
URL: http://www.dr-bob.org/babble/psycho/20050129/msgs/450284.html