Tips for charting if you are not using an EMR.

Not having an electronic medical record can make it so easy for little things to slide by… proactive audits of your own charts and having others look them over protect you from insurance take backs and liability problems.

In general:
1. Every paper in a chart (including the intake paperwork, DSM scales you used for assessment, drawings done by client, journal entries they bring in, worksheets, etc) needs the clients name and date at the top, as well as your signature and date at the bottom.    
 
2. All aspects of the detailed progress note need completed in order to be compliant with insurance requirements for all in person points of contact.
 
3. Document all phone calls, print all e-mails and do a note for all late-cancels/no-shows (document how you contacted them or they contacted you, whether they were charged and why, and follow up plan). These notes should NOT indicate in\out time, modality, persons present, etc
 
4. Notes need completed and filed before you leave on dates of service. Tragedy can strike you or client at any time.
 
5. Time in and out must match modality you are billing, name must match the legal name being used by insurance or on client’s ID and that name must be on all forms. If there is a different preferred name, you can indicate that in quotes. Ie: Melinda “Mark” Smith, or Aaron “Joe” Smith.  If a couple/family is being seen, all documentation needs to be under the identified/billed clients name and from their perspective….all references to other people are “client’s husband states… or Mark states” etc.  Also get multi person release signed.

I have been audited before (not fun) and have recently discussed documentation standards with board.  They are clear on the above-mentioned issues and insurance companies can take back money for any of the above issues as well.
 
Helpful hacks:

• Take one week to commit to flipping through your charts of clients seen each day that week
• Ask a peer to go through a chart of two for you and offer to reciprocate
  
• At the start of each day, fill out the client name at the top of a detailed progress note to increase likelihood That you do a note for no-shows and late-cancels.

Tip from a real clinician -

ALEXANDRIA BERESFORD  MSW, LISW-S, DBTC

Alyx Beresford MSW, LISW-S, DBTC is a Licensed Independent Social Worker and obtained her Bachelors’ degree from the University of Cincinnati and her Master’s degree from the University of Kentucky. Alyx is the director of the DBT® Center at Compass Point, the Training Center at Compass Point and operates as co-clinical director for Compass Point Counseling Services.

See more about Alyx

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