If you have been practicing in the Allied Healthcare space for years or are a new practitioner, you likely have heard the saying, “If it wasn’t documented, it wasn’t done.” This may have been taught in your training to enter your profession. Proper documentation is not as clear-cut as this statement, however. Documentation is critical, but there are also times when certain observations or occurrences may not be memorialized when documenting in an electronic medical record (EMR) or in written format. Although this resource may not be exhaustive of all the principles, here are some important tips to keep in mind. If you work in an office or facility, it is critical that you become familiar with and comply with your employer’s guidelines regarding documentation. If you believe there is a conflict between the ethics code of your profession and your employer’s guidelines, it is best to consult a risk management specialist or an attorney for guidance.

Why Is it Important to Document?

Many of you work in systems where EMRs are used; however, some of you may still document in written form. In either scenario, documentation is important to memorialize the care provided to the patient. It serves many purposes including:

• Contributes to improved patient care and minimizes errors
• Promotes patient safety
• Ensures compliance with rules and regulations in your state
• Recognizes professional standards of practice
• Supports billing/reimbursement for services
• May assist your attorney in defending you in a lawsuit or board complaint

Documentation is standard in any Allied Healthcare profession. When documenting, always consider who will be reading your record and why. You certainly do not want to always document with the fear that you will face a board complaint or lawsuit. However, document objectively so a third party reading your record will be aware of the symptoms presented and the care provided. Be sure to check your profession’s ethical guidelines on documentation principles.

Objective vs. Subjective Documentation

No matter which Allied Healthcare profession you are practicing in, from social work to physical therapy, documentation should be objective, not subjective. It should not be judgmental, but should be an accurate, descriptive representation of what you observed and heard. Keep in mind the types of documentation may vary depending upon the area of Allied Healthcare profession in which you are practicing, but a few examples to illustrate objective versus subjective documentation.

1.Subjective:
“Patient appeared drunk.”

Objective:
“Patient was observed with glassy eyes, stumbled and staggered as he entered the office. Patient had a strong odor of alcohol on his breath.”

2. Subjective:
“Patient is non-compliant with treatment”

Objective:
With each missed appointment or non-compliance, examples of documentation may include: “Patient no-showed for his scheduled appointment.”

“Patient indicated she is taking medication 3 times per week and not daily as prescribed.”

“Patient’s treatment plan reflects exercises 3 times per day at 10-minute increments. Patient indicated he has been performing his exercises 1 time per day at 5-minute increments and is reportedly limited by pain and discomfort.”

3. Subjective: “Patient was hostile and angry.”

Objective: “Patient had a loud tone of voice and stated, ‘I hate coming to see you, and I’m not coming back anymore if you are going to ask me those questions.’”

When to Document: Timing

This is a common issue that many Allied Healthcare professionals face. You may face a myriad of daily occurrences that impact your ability to document. Some of these occurrences might include mounting requirements from insurers, back-to-back scheduled patients, emergency issues, phone calls for prior authorization or other issues which occur daily.

You may think, “I will get to this later.” However, it is important to document as close in time to the patient appointment as possible. Say for example, you were unable to document a patient’s appointment until the following day, and the patient goes home and contacts you to indicate that an issue occurred. It is far better to have documented the encounter and then add an addendum when the patient contacts you rather than documenting all in one note. Likely if you are using an EMR, your note will be time-stamped, so it will reflect when the documentation actually occurred.

Is an Addendum or Correction ok?

The short answer is, yes, an addendum or correction is ok, and actually is needed to clarify the care or to correct misinformation. It must be clear, however, that your addition to your previous note is an addendum or correction. Avoid an addendum or correction that may appear self-serving or is not substantive. Never erase or destroy the original note in a record. If using an EMR, your initial documentation may still appear in the record in crossed out form so any third party reading the record can still see the original documentation as well as the addendum or correction. Always note the reason for the addendum or correction and the date it was made (if not using an EMR).

What Should or Should Not be Documented?

This will depend on the patient, the type of care you provide, and the specific circumstance of the case. Your record may include:

• Patient’s history
• Medication dosages and the prescriber’s name
• Signed informed consent for:
• Billing
• Treatment
• Communication with other providers, family members, etc.
• Date and time of patient encounter/session
• Objective documentation of compliance (see above) and progress
• Any boundary issues between you, other providers
• Proper termination when care ends, even when the patient terminates care
• Formal consultations with other providers
• Depending on your type of practice, suicidal or homicidal history or ideation and actions taken
• Any relevant information to support the care provided
• Documentation of reasons if you deviate from standard treatment

It is important that you are aware of any state requirements for documentation.

Things to Possibly Avoid in Documentation

There are times you may need to be cautious about what to document. As mentioned, check to see if your state has rules about documenting information on third parties, including names, and if there are rules indicating a third party may have a claim against you if you release records with his/her name, even if the person is not your patient. Seek guidance if necessary. In addition, here are a few things to potentially avoid (keeping in mind this depends upon the patient and the circumstance):

• Abbreviations that differ from the acceptable, standard abbreviations
• Blank spaces/pages when documenting in written form
• An informal or curbside consult. Unlike formal consultations, informal consultations are not typically documented. This is not across the board and may vary depending on your facility.
• Avoid documenting words such as “error,” “mistake,” “accident”
• Issues that are not vital to treatment
• Subjective documentation (as indicated above)
• Finger pointing or placing blame on another provider

Electronic Medical Records

Many practices or facilities are using EMRs at this point, and it will continue to grow as time continues. If you are documenting in an EMR, keep in mind the following:

• It is important to never give your login or password information to another provider.
• It is not advisable to use cut and paste options. There are times when a professional documents the wrong diagnosis or information about a patient and then that same information is used throughout the record going forward by those who use the cut and paste option.
• When documenting, make sure you are documenting on the correct record. Be aware of patients’ names which may be similar or circumstances which may be similar.
• Use approved abbreviations.
• You may have occasions when you treat different family members or patients who know one another. While doing so may raise other issues to consider such as possible dual roles or confidentiality, with respect to documentation, it is important to avoid using the name of the other patient and to instead refer to the other patient by his/her EMR number.
• Make sure to use an encrypted system, particularly if using portable devices such as a smart phone, tablet, or laptop.
• Know the law in your state on how long you are required to retain medical records. This time frame may vary as well depending upon the patient’s age (for example, if the patient is a minor).
• Your EMR should be backed up regularly. It is important that a system is in place in the event there is a technical system or failure.

Psychotherapy Notes

This may not be applicable to all Allied Healthcare professionals. However, to the extent that you document psychotherapy notes or interact with professionals who do, there are a number of factors to keep in mind. Psychotherapy notes are discussed in HIPAA¹. Psychotherapy notes are notes recorded by a behavioral health professional documenting/analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session. Psychotherapy notes do not include information about medications, start and stop times, treatments, results of clinical tests, summary of diagnosis, functional status, treatment plans, symptoms, prognosis, and progress². They are the personal notes of the provider and differ from progress notes which are part of the medical record.

Psychotherapy notes are afforded a higher level of protection from disclosure than non-psychotherapy documentation under HIPAA. However, they must be kept separate from the medical record. If they are intertwined, they lose that level of protection. If you are documenting in written format, keep psychotherapy notes separate from the record. This may be problematic as some EMR systems do not have the capability to separate out psychotherapy notes from the record. When using an EMR, be aware if the notes are separate or not. If your EMR system does not have the ability to separate out psychotherapy notes, keep separate written or electronic psychotherapy notes. If in electronic form, ensure they are safe, secure, and encrypted. If they are kept in written form, ensure they are secure and kept in a locked location. If you are unable to do either, you may consider not documenting psychotherapy notes in addition to the documentation in the patient’s medical record. Even if you do not document psychotherapy notes, you may be a professional who requests a record from another professional who does. Be aware if your state has a specific rule on psychotherapy notes as it could differ from the HIPAA rule.

Termination

Termination can be a tricky issue. You may need to terminate care for a variety of reasons. Know what the rules are in your state and what your ethics code says about what constitutes proper termination. Even if the patient terminates care or simply stops coming to sessions, know your state requirements for termination. Additionally, there may be times when you feel you have to terminate care immediately; for example, a safety concern. It is important to obtain expert consultation to determine if and how you can immediately terminate care. Always ensure you memorialize the termination in writing.

Documentation in Lawsuits or Board Matters

As indicated above, your record may be critical in a lawsuit or board matter. Your record may be looked at by your attorney, the opposing attorney, and depending on the issue, the board investigator or a jury, as well as the patient and his/her family. A medical record is a legal document, and it is important that your documentation is thorough. You may or may not even remember the patient when the care is being examined, and it might be many years after your encounter. It is important that your documentation reflects the care provided and the issues addressed, and that it is a factual account of what occurred. Always remember how your documentation would appear blown up on a screen in front of a jury. Would it appear professional and reflect the care provided?

Text and Email Communication

Texting

If you engage in text communication with patients, first you should have an office policy concerning when it is appropriate to communicate with you via text and a signed informed consent document which highlights possible privacy concerns when using text messages. It is important to have consistent rules about what types of communications patients are able to communicate with you via text. Also, you cannot ensure a party other than your patient may receive your text. Your patient may leave his or her phone on the counter, table or unattended. Therefore, the text you send may not be received by your patient. These risks should be addressed in your informed consent with the patient. Make sure you take a screenshot of any text communication to memorialize in the record. If it becomes apparent that you cannot continue to communicate with your patient via text, for whatever reason, ensure that the process for ending such communication is incorporated within your policy, and ensure you memorialize this change by sending a letter to the patient that texting is no longer able to be used. Should you have an emergency issue arise over texting, be aware of how to seek emergency services/response for the patient.

Email

Ensure you have a policy on email communication and that is discussed at the outset of treatment. Ensure you have a signed informed consent document which highlights possible privacy concerns and risks associated with using email. When communicating with patients through email, use encryption. Be aware that if you are communicating with a patient through his or her work email, it does not have the privacy it would if you are communicating via his or her personal email. A work email is owned by the company, not the patient, and there is no reasonable expectation of privacy. As such, if you end up having a lawsuit or a board issue, even if your care is not at issue, your email communication may not be kept confidential if sent to a work email account. If you do not check your email off hours or if away, ensure you have an auto-response that reflects this along with what to do in the event of an emergency.

At the end of the day, you are the protector of your patient’s information, and if you end up communicating by text or email, it is important to maintain patients’ privacy.

Conclusion

There are many issues to consider when documenting patients’ treatment. Keep in mind that whether you document electronically or in paper format, you must document the treatment provided. In addition, be aware of applicable state and federal laws on documentation. Finally, failing to document could impact you both professionally and personally. Should you have any questions about documentation, contact an attorney in your state or a risk management professional.

Author: Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM, Healthcare Practice and Risk Management Innovation Officer

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¹ DHHS, OCR, HIPAA Privacy Rule and Sharing Information Related to Mental Health. https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf [last accessed April 30, 2019].

² 45 CFR 164.501, DHHS, OCR, HIPAA Privacy Rule and Sharing Information Related to Mental Health. https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf [last accessed April 30, 2019].