Standard 5.1 Record-Keeping - Clinical Records
Some may be associated with a group of professionals, including other therapists. In all cases, record-keeping is an important component of good client care. The clinical record serves as an important reference document and should be complete and accurate. Clinical records Clinical records encompass a client profile personal information provided by the client at the outset of the therapeutic relationship and corresponding treatment records.
They are kept on a client-by-client basis. When more than one person e. However, when the couple or family attend in different combinations, the member should generally keep separate files or sub-files for each individual. For example, if one member of a couple attends for an individual session, a file for the individual session should be maintained separately from the file for the couple. Similarly, in a group therapy setting, records for the group may be maintained in one file. A unique identifier is a code e.
If using unique identifiers, members must securely maintain a key linking each client to their unique identifier. The clinical record should also include where relevant: the date of every consultation the member receives from another healthcare provider, or the member provides to another healthcare provider, regarding service provided to the client; specific information related to any referral made by the member regarding the client; notes, forms and other material, regardless of the medium or format i.
Maintaining separate records RPs may maintain additional notes and documentation, e. It is important to note that the entire record must be managed in accordance with legal and College requirements. The record, including any separately maintained notes and documentation, must be made available to the client upon request in accordance with PHIPA.
In addition, disclosure of the entire record to a third party may be legally compelled, and members should exercise caution when considering what information to include in the record. If the client was self-referred, this should be noted as well.
Plan for therapy The plan for therapy will depend on particular circumstances including the therapeutic approach or model used. It will also include any reports on tests administered to the client. As the therapeutic relationship continues, changes in the therapy plan will also form part of the record. The initial plan establishes the direction of therapy and helps guide future sessions and evaluate change.
The therapy plan may be updated, and will include both subjective and objective information. Subjective information is relevant information provided by the client. Objective information is relevant information observed by the member. Client contact The record includes a notation of all in-session and out-of-session contacts with a client, including any advice or directives given. Examples of out-of-session contacts with clients include letters, emails, texts, telephone calls and videoconferencing.
The documentation should provide a clear record of the incident, which can be used to explain the event and relevant details surrounding it. Mandatory reports There are certain circumstances where federal or provincial laws require the member to advise a person or organization of a serious concern e. Members keep a record of all such mandatory reports they make.
If the report was not made in writing, members maintain details of the report in their records. Amending records Every entry into the clinical record indicates who made the entry and when.
If an amendment to a record is needed, the amendment should indicate what change was made, when, by whom, and why, making sure that the original entry is still legible.
Accessibility of records Records are prepared and maintained in a timely and systematic manner. Regardless of how the information is structured or stored, it is important that client records are easily accessible. The Standard: Record-keeping — Clinical Records Members keep an accurate and complete clinical record for each client.
Members provide access to legible client records, when requested to do so by a client, authorized representative or another legal authorization. College publications are developed in consultation with the profession and describe current professional expectations. It is important to note that these College publications may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.
How To Write Therapy Progress Notes: 8 Templates & Examples
Gary M. Not a member? Psychotherapists are becoming busier every day and are constantly trying to manage the many different responsibilities they have with the increase in demand for psychological services. Responsibilities can include assessment, treatment planning, clinical preparation, individual therapy, group therapy, case management, case consultation, documentation, coordinating care, supervision , training, and outreach.
One setting that has been heavily impacted by this increase in demand is university counseling centers. Further, they reported , individual college students sought mental health treatment during the school year. However, they reported only 3, clinicians from colleges were available to meet this need. While students are seeking treatment more frequently, clinicians at counseling centers are struggling to find ways to manage this increase in demand. There are several approaches to this problem.
For example, some clinicians increase the time clients wait between sessions, seeing clients every two weeks instead of weekly, which enables them to be able to see twice the number of students. Another approach is to create waitlists. This allows clinicians to avoid taking on more clients than they can reasonably care for while maintaining a shorter interval that clients wait between sessions.
However, this means that many clients must wait for extended periods, sometimes months, before talking to a therapist at all. This of course can also be problematic, especially with clients who have high risk concerns like suicidality.
Another method is to decrease the number of intakes being offered. When intakes are decreased, the impact can be the same as a waitlist, as intakes are not available for clients for up to months at a time, meaning that they again end up waiting before being seen. Other counseling centers will eliminate intakes altogether, informing prospective clients that they will not be conducting additional intakes until the following semester.
At that point, the general practice is to provide students with resources they can pursue for services elsewhere. Finally, some counseling centers create more therapy groups to address the increasing demand for services. In a group, a single clinician can meet the needs of several clients in 90 minutes as opposed to meeting the needs of a single client in 50 minutes. Individual Versus Group Therapy There is an ongoing debate about the effectiveness of individual versus group therapy.
Within these studies, there are several methodological flaws to take into consideration. One major flaw was noted when a meta-analytic study compared individual psychotherapy outcomes in one study with group psychotherapy outcomes in another. This is problematic for several reasons. For instance, when comparing outcomes across studies, therapists are often compared who work at fundamentally different settings, thus negating the potential impact of the setting.
There are also different diagnoses and even different treatments being given within the individual and group conditions. Additionally, researchers may not be clear as to which outcomes are primary or secondary.
For example, studies looking at obsessive compulsive disorder may not identify outcomes specifically related to their key hypotheses, such as labeling the Yale-Brown Obsessive Compulsive Scale Y-BOCS; Goodman et al.
As such, comparing outcomes across studies leads to non-equivalence within the conditions, making it nearly impossible to accurately report findings. Even in meta-analyses where this flaw is not present, there are similar non-equivalent methodological issues. Specifically, individual psychotherapy and group psychotherapy comparisons within the same study may be nonequivalent in other ways, such as different total number of sessions, different time dosing, different therapists throughout the treatment protocol, and differing diagnoses.
Thus, even studies that compare individual and group therapy directly can make it difficult for researchers to accurately compare the two conditions, given the irregularities between conditions. Lastly, a limitation of meta-analyses is the interpretation of the average effect size in making conclusions without considering the amount of variability of studies used in creating this average. If the aggregated studies produce small effect size variability, or low heterogeneity, then we can have greater confidence that the average effect size is truly representative.
However, if there is a wide discrepancy between studies, or high heterogeneity, then less confidence can be placed in the average effect size. Up until now, both equivalent and nonequivalent studies have been aggregated together to highlight the current literature findings on individual versus group psychotherapy effectiveness.
Last year, we conducted a meta-analytic review that addressed these crucial issues Burlingame et al. We screened over articles and found that the most frequent reason for exclusion was the absence of direct format comparison and the publication being a review, meta-analysis, or unpublished study. Of the articles, 68 articles included both individual and group treatments in the same publication, and were included in the meta-analysis. First, we hypothesized that individual and group format for identical treatments offered in the same study would demonstrate treatment equivalence.
Second, we hypothesized that individual and group format for nonidentical treatments offered in the same study would show treatment differences. In other words, we statistically tested outcome differences between individual and group formats when treatment conditions were both equivalent and nonequivalent.
We conducted three separate comparisons to analyze these outcome differences and test our hypotheses. First, we performed an omnibus test of all treatments both identical and nonidentical and all outcomes primary and secondary.
Thus, meta-analysis of 67 studies that directly compared individual and group formats found equivalence with moderate heterogeneity when primary and secondary outcomes were both combined and separately analyzed. Therefore, when we examined both identical and nonidentical studies on all outcome measures we found no differences between the outcomes of group and individual formats.
Both formats showed equivalent pre-post outcomes with high heterogeneity, which was partially explained by diagnosis. Patients presenting with depression, substance use, anxiety, or eating disorders showed the highest level of improvement.
Second, to test our first hypothesis we conducted a meta-analysis of 46 studies that met criteria for format equivalence and identical treatment comparison. When only primary outcomes were analyzed, format equivalence was found with no significant heterogeneity.
We view this test of primary outcomes as the best test of our first hypothesis since it compares identical formats on the symptoms targeted for treatment.
This finding provides strong support for the notion that no differences in outcome exist when identical individual and group treatments are compared across homogenous and diverse patient populations. Lastly, to test our second hypothesis we conducted a meta-analysis of 21 studies analyzing format differences for nonidentical studies.
Results showed group and individual format equivalence with significant heterogeneity. In contrast to identical treatments, meta-analysis of primary outcomes did not reduce the heterogeneity. However, allegiance was one moderator that explained this variability in heterogeneity. In other words, studies in which researchers expressed allegiance to either group or individual therapy produced effect sizes that favored the preferred format.
Researcher allegiance is a common moderator in psychotherapy meta-analyses Lambert, , therefore, we expected it would appear in studies testing format differences. As such, when interpreting nonidentical treatment format studies, it is important to be cautious, particularly when the authors reveal an allegiance to a format.
Stated differently, since the effects of allegiance can only be revealed through meta-analysis of multiple studies, clinicians and researchers should exercise caution in applying the findings of any nonidentical treatment study, especially when format allegiance is present. Clinician and Patient Implications This is the largest format comparison meta-analysis that we know of, and the overlap between our findings and past meta-analyses increases our confidence in the conclusion that when identical treatments, patients, and doses are compared, individual and group formats produce statistically indistinguishable outcomes.
However, groups come with a unique set of additional responsibilities when compared to individual therapy. For example, additional tasks include finding enough clients to begin the group, pre-group screening sessions, progress notes for each group member per session, progress notes for the group as a whole, and managing attrition. Although there are logistical challenges, encouraging clinicians to run groups may help fulfill the aforementioned issue of demand clinicians are facing, especially given our conclusion that groups and individual therapy produce statistically indistinguishable outcomes.
Individual vs. Factors affecting treatment efficacy in social phobia: The use of video feedback and individual vs. Journal of Anxiety Disorders, 23, 12— Prospective randomized study of individual and group psychotherapy versus controls in recipients of renal transplants. Kidney International, 65, — An experimental study of brief unilateral intervention for the partners of heavy drinkers.
Research on Social Work Practice, 6, — Changes in psychoneurotic patients with and without psychotherapy. Journal of Consulting Psychology, 19, — Group versus individual cognitive treatment for cognitions at post-treatment and one-year follow-up.
Psychiatry Research, , — A psychoeducational approach to the treatment of depression: Comparison of group, individual, and minimal contact procedures. Journal of Consulting and Clinical Psychology, 52, — Group versus individual cognitive treatment for obsessive-compulsive disorder: Changes in severity at post-treatment and one-year follow-up.
Behavioural and Cognitive Psychotherapy, 38, — STA Goodman, W. Development, use, and reliability. Arch Gen Psychiatry, 46, Cole, R. Effectiveness of prediabetes nutrition shared medical appointments: Prevention of diabetes. The Diabetes Educator, 39, — A nonrandomized effectiveness comparison of broad-spectrum group CBT to individual CBT for depressed outpatients in a community mental health setting. Behavior Therapy, 40, — Are individual and group treatments equally effective in the treatment of depression in adults?
A meta-analysis. European Journal of Psychiatry, 22, 38— Problem solving treatment and group psychoeducation for depression: Multicentre randomised controlled trial. British Medical Journal, , — The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis. Clinical Psychology Review, 30, 25— A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clinical Psychology Review, 24, Efficacy of nonmedical treatments of depression in elders: A quantitative analysis.
Journal of Clinical Geropsychology, 3, 17—
Psychotherapy Notes vs. Progress Notes
How to Develop a Treatment Plan Developing a treatment plan is a lot like pulling out an old AAA map, spreading it out on the kitchen table, and evaluating all the different ways to get to your destination. What Makes a Good Treatment Plan?
Streamline your entire workflow
Problem Statements — Problem statements identify the issues the client has expressed interest in addressing. Goals — Therapy goals are the 30,foot view of what you plan to help your client accomplish. Be sure to make them specific but broad enough to cover several smaller objectives, and clearly connect the goals to the problem statements. Objectives — Objectives are like mini-goals, the individual steps that need to be taken to achieve the primary goal. The interventions you use may be different for each goal, and they may change.
10+ Therapy Progress Note Examples [ Clinical, Anxiety, Illness ]
Nothing in the plan is set in stone. Was the client involved in creating this plan? Their prior experience with therapy, education level, family background, lifestyle choices, and many other factors all come into play when creating a custom treatment plan. If appropriate, the use of rating scales or other assessments can help both better understand the impact and severity of each issue, making it easier to know where to begin.
Having a client complete an exposure hierarchy is a good example of the type of informal assessment tool used to customize a treatment plan. Read Elements of a Clear Counseling Treatment Plan to learn more about how to write an effective treatment plan.
How Good Progress Notes Can Help You Implement a Plan More Effectively Writing therapy progress notes creates a session-by-session accounting of the twists and turns that a course of therapy inevitably takes.
Individual vs. Group Psychotherapy
Just as no battle plan ever survives the first engagement, your treatment plan will need to be adjusted over time, and progress notes guide you in that process. Progress notes also make it easy to see how much progress has been made toward specific goals, and when objectives have been met. And they can be a catalyst for celebration and encouragement when a client meets key milestones. Put the results of the tests, documents, etc. Determine the type of intervention used. Sign the documents for validity.
FAQs What are the frequently used interventions? Anger management, coping strategies development, identifying triggers, mindfulness, imagery, stress management and more.
What intervention should be used when dealing with trauma? In dealing with trauma, they use the eye movement desensitization and reprocessing intervention during the counseling session.
What is the difference between having a group progress notes and individual progress notes? Group progress notes do not identify information for the clients while the individual progress notes describes how an individual client engage within the group including the information about the diagnoses, treatment plan, etc. Those treatment plans and progress notes help you in understanding your clients better. You cannot disclose your psychotherapy notes to others without your client first signing a detailed authorized form specifically for the release of these notes.
There may, however, be instances where you have to release your psychotherapy notes by law, or in compliance with administrative requests from government agencies.
The Privacy Rule safeguards your psychotherapy notes by not only giving important rights to your clients but also to you as the treating practitioner.
Although your clients have a right to view most of the health information held about them, including your progress notes, they do not have a right to inspect your psychotherapy notes. Therefore, you do not have to fulfill client requests for access to these notes.
You must, therefore, put appropriate administrative, physical and technical safeguards in place to ensure the confidentiality, integrity, and security of your notes. You must also keep your electronic psychotherapy notes separate from your electronic progress notes to ensure that your psychotherapy notes remain off-limits to others. If you use psychotherapy note software, you will benefit from primers and other tools that ensure you have the measures in place to protect your notes and avoid costly regulatory enforcement.