Documenting Psychotherapy: Getting Hep on HIPAA

Abstract

everal decades ago in my residency training at University Hospitals of Cleveland we kept two charts on every patient in the outpatient clinic. The official medical record circulated throughout the general hospital and slept in Medical Records when not in use. The other folder was in a locked filing cabinet in the Adult Psychiatry clinic. Into the official record went all the information another clinician seeing the patient would need to know, including a simple statement that psychotherapy took place. The confidential chart was another story. Since we were learning psychotherapy, we wrote detailed notes describing what went on in treatment sessions. Sensitive factual details about the patient and significant others went there also. We even ventured some thoughts about our own reactions to the patient’s thoughts and behavior, and how to understand and respond. We went over this information regularly with our supervisors, most of whom were psychoanalysts. We worried about those confidential charts. Would they be called into court some day when the patient got into a custody battle or made a claim for pain and suffering in a liability suit? Could we use them if we were sued by the patient? Would unauthorized people get into those filing cabinets? The legal status of the confidential records was uncertain. We knew they could be subject to a subpoena, but maybe we could get the hospital to fight it. We were told that this had never happened, so we shrugged off our worries. Nonetheless, we were careful not to be flippant or irresponsible in what we wrote. Along came managed care, the dangers of retrospective review by insurance companies and dreaded Medicare, and, more recently, central computerized records. The plot got even thicker. One had to be very careful not to put too much or too little in the medical record, because so many eyes could view it. The idea of patients’ rights to review their own charts was catching on. There had to be enough clinical data to justify a diagnosis and a rationale for the treatment plan. That meant a factual history of the present illness and relevant past and family history, a good mental status exam, lab results, and records from other sources. Medications and their aftermath belonged there. When coding for Psychotherapy with Medical Evaluation and Management (E&M), a psychiatrist had to include at least some elements of assessment, medical decision-making, and management. The “SOAP” formula came in very handy.