Easy Cheese in the Mousetrap

First, we want to recognize the behavioral health and social work professions as genuinely noble, founded on service, integrity, and clinical expertise. The profession can often be stressful and very dangerous. The nation is grateful for what you do—AND SO ARE WE! Thank you!

Pro-Tip: Charting Well Ends Well

Preferra’s experience in claims adjudication and legal defense of social workers has identified a loophole that plaintiffs’ attorneys use to enhance their lawsuit allegations. Flawed documentation allegations are a broad lawsuit category with generalizations that serve as “easy cheese” in the mousetrap for plaintiffs to claim damages arising from negligence and malpractice.

Client documentation flaws, such as lack of detail, failure to state services provided, repeated statements automatically inserted by artificial intelligence software across a series of therapy sessions, case note templates with repeated terms to streamline notes, speech-to-text software errors, sloppy notes, and omitted or infrequent therapy notes, are “easy cheese” in the mousetrap for plaintiff attorneys to prove negligence and malpractice.

For over 10 years, Preferra claims management has seen many lawsuits with allegations of poor client documentation that sting practitioner defendants. Recently, we have seen court judges rule documentation evidence as flawed and incriminating for the social worker because of the repeated identical statements that appear in the case notes. The result is that identical therapy session notes repeated time after time are viewed as faulty, pointing to culpability, negligence, and failure to meet standards of care.

Stick to precise detail when writing therapy session notes. Writing that “the client seemed unhappy” is too general. Detail is needed, such as “the client experienced bouts of depression, was unable to sleep, felt frightened over certain circumstances, and was unable to speak with people.” Best of all, include quantitative data scores gained from behavioral tests and evaluations in the case notes.

What is Charting?

A preliminary literature search provides some answers.

The SOAP Case Note Template:

This method is used for general therapy without clear guidelines. First, document the client’s subjective disposition and thoughts. Second, switch to more objective observations regarding the client’s situation and external circumstances. Third, based on the data and findings thus far, develop an assessment of the issues that need to be acted upon, with the most serious and acute at the top of the list. Fourth, create an action plan that addresses the challenges on the list. (Caseworthy.com offers a useful template for case notes, but make sure you avoid the mistakes identified in the aforementioned paragraphs.)

The DAP Case Note Template:

This method includes therapy note structuring based on three primary elements: Data, Assessment, and Plan. This is a structured format with the detail that insurance companies require. The DAP notes are a function of the client’s progress. The notes build on each other incrementally through changes in the treatment plan and client progress. Generally, the more change in the client’s progress between each session, the more documentation notes are recorded. Client quotes are important to include in therapy documentation, with brief, concise, and factual observations that are objectively written.

Examples of Data elements include the client presenting the problem, mental status, appearance and hygiene, session interventions, and client response to the interventions. Stick to the facts, not a general feeling of how the session went.

Examples of Assessment elements include using clinical expertise to assess the client and record observations and interpretations through documentation notes. Note any changes in the client’s self-identified diagnosis, self-harm or suicidal thoughts, homicidal thoughts, general progression, and changes in the client’s goals. The practitioner adds interpretive assessment details to the notes.

Examples of Plan elements include referrals, suggestions for the client to pursue, client assignments, and treatment goals, all with time-specific details including prospective client session scheduling.

The BIRP Case Note Template:

According to ICA Notes, Behavioral Health (see: “BIRP Notes Guide for Mental Health Professionals,” by October Boyles, 8/18/2021), BIRP notes templates are a consistent and widely accepted standard format for client documentation and for use in referral to other healthcare providers. BIRP organizes therapy documentation into four specific sections: Behavior, Intervention, Response, and Plan. BIRP notes are a continuous clinical record of client progress and are considered the most important use. Practitioners rely on BIRP notes for billing, insurance reimbursement, and client therapy planning.

Examples of Behavior include problem presentation by the client and overall observation of subjective and objective elements. Elements include client quotes (limited to relevant, concise, and focused content), symptoms, thoughts, appearance, temperament and mood, and the practitioner’s impressions from the dialogue and assessment.

Examples of Intervention focus on reaching treatment goals and documenting how the practitioner’s methods were administered. Notes should include the questions asked, client responses, and a detailed account of the tactical therapy actions utilized. Using action verbs in the documentation notes is useful in showing active therapy with the client, such as: encouraged, modeled, role-played, reviewed, supported, taught, prompted, validated, and recommended. These words link treatment to the original observation and problem identification. Also, list any other therapy utilized, such as art therapy or cognitive behavioral therapy.

Examples of Response include notes regarding the client’s response to your interventions during the session and to the therapy as a whole. Recording detailed client reactions is key. Use direct quotes to gauge both positive and negative client reactions. Document in detail any abrupt changes in the client’s response to therapy.

Examples of Plan in BIRP notes include treatment goals and planned progress over time during the next session and series of sessions with scheduling. The plan for the next session and for the entirety of treatment should address the following questions:

• What did you identify or will you discover in the sessions?
• Is the client determined to recover?
• What are the client’s goals, and have they changed?

As with any template documentation technique, there is a trade-off between thoroughness of therapy documentation and time allotted to writing the documentation after the therapy session is completed. Some recommend two or three statements per section with a set time limit for post-session documentation creation.

This is where the great trap exists. It is tempting to rely too much on electronic health records templates to create therapy notes in order to save time. Do not get caught in the intuitive aspect of software, computer templates, and artificial intelligence substituting convenient terms and assessment clauses into your therapy notes. This “boilerplate” redundancy and duplication among therapy sessions is where the repeatability in the therapy documentation becomes the “easy cheese” for plaintiffs’ attorneys.

While all of these documentation tools and approaches have a similar beginning, middle, and end, they are all exposed to charting diminution due to time constraints, reliance on pre-fabricated statements, and carelessness. When charting documentation, be on point, factual, thorough, link notes to therapy goals and treatment, preserve client uniqueness, and be detailed… “dot the I’s and cross the T’s.” The choice is yours to stay out of court.