Lessons Learned: The Importance of Clinical Documentation

Lessons Learned: The Importance of Clinical Documentation

By Don Wiger, Ph.D., LP

This article is the second in a series of six by Don Wiger. The first article, titled “When You Leave a Clinic: Keep Your Reputation,” appeared in the May-June issue of the Minnesota Psychologist. Parts three through five of this series will explain how to measurably document intakes, treatment plans, progress notes, and outcomes.

What happened? I am proud to have graduated from an excellent graduate school in New York. The first few months of living in New York City, especially as a single parent, were a true cultural shocker for this Minnesota boy. Nevertheless, we adapted and learned much about who we were by living away from home.

In graduate school, I learned from some excellent teachers. To work at this university, instructors had to be quite experienced and well-published--they were clearly experts in their fields. Academically, the program was challenging, but well worth the price paid in time, effort, and personal sacrifice.

When I graduated, I soon took a job as a teacher, counselor, and statistician at a small college in South Carolina. This was great, because I was able to teach, counsel students, and obtain my post-doctoral experience. However, because my training and experience, to date, were typically gratis services for clients, I had few documentation requirements. That is, the treatment plans and progress notes were skeletal, at most.

Of course, this Minnesota boy eventually moved back home. I took a job at a clinic in which I was the only doctoral level psychologist; thus, it was assumed I was quite knowledgeable in most aspects of clinical services. Now, I would be supervising people. However, my training in clinical documentation was minimal.

In the early 1990s, I decided to start my own practice. Having learned about self-employment from my father, I had some knowledge of what it takes to start a business. It is hard work to provide unique services and regularly advertise to potential consumers or referral sources. Within a few years, the practice was running several groups, had a full load of individual clients, and I had found a niche in conducting psychological evaluations.

Because the business grew so quickly, it apparently raised a red flag with Medicaid, and I was contacted to have an audit. When the auditors showed up, they explained the audit was being conducted because the amount of billing had gone from nothing to a fairly high amount in just a few years. The auditors spent a number of days going through records, checking intake notes, treatment plans, progress notes, and appropriateness of services.

A couple months later, the auditors set up a meeting to inform me that I owed several thousand dollars. I was shocked because, to my knowledge, the practice had done nothing wrong. They let me know that, although we followed their guidelines in areas of obtaining a diagnosis, frequency of services, and having a case note for every session, that wasn’t enough.

The auditors, who were not even trained in psychology, provided an education in documentation that was never taught to me in graduate school. They carefully explained the concept of medical necessity, and I learned that my documentation, from the intake, until the termination of services, MUST clearly and measurably document the ongoing need for services. I also learned that you do not have to be a trained psychologist to learn documentation. I learned from the auditors as much as I had gleaned from any professor. Psychotherapy skills, in themselves, are not enough in this age of accountability.

Lesson Learned: Clinical knowledge of psychology or counseling theories is necessary, but not sufficient, in the training of a practicing psychologist. Third party payers have specific guidelines and regulations that determine if the services performed by mental health professionals meet their criteria of medical necessity for services. If there were no such requirements, seeking reimbursement would be similar to paying someone continually to make repairs on something that has never been proven to be broken.

Donald E. Wiger, Ph.D., LP, is a licensed psychologist with a private practice in St. Paul. He has conducted seminars and consultations in documentation since the 1990s. He has written several books on topics such as clinical documentation, practice management, clinical interviewing, and record keeping. Dr. Wiger earned his Ph.D. in 1989 from Fordham University in New York City from the Department of Psychology, specializing in psychometrics. He has an MA (1986) in experimental psychology/psychometrics from Fordham University and an MS (Ed.) (1984) degree in counselor education from the State University of New York.

Share this post:

Comments on "Lessons Learned: The Importance of Clinical Documentation"

Comments 0-5 of 5

- Wednesday, January 31, 2024
2014782929

TRENDING LOTTERY LUCKY WINNING NUMBERS TO HELP YOU WIN THE LOTTERY... Priest Ray is the best lottery spell caster and his lottery numbers strike without any problem. I used his lucky winning numbers and I won the sum of $48m. I came across Priest Ray contact through a comment on YouTube when someone testified about his lottery lucky winning numbers because I was searching for tips to improve my chances of winning the lottery. I contacted Priest Ray and told him I needed the lucky numbers and he did the rituals within 24 hours he sent me the winning numbers which I played and won $48m. You can also reach him to get your lucky winning numbers by email: [email protected] or WhatsApp: +12133525735 or visit his website: https://psychicspellshrine.wixsite.com/my-site

- Monday, January 01, 2024
2013491608

Hi everyone I am Emily Naomi wanna give a big thanks to this wonderful psychic for bringing my husband back to me… I never really believed in magic spells or anything spiritual but a trusted friend opened my eyes to the truth about life. My marriage was heading to divorce a few months ago. I was so confused and devastated with no clue or help on how to prevent it, till I was introduced to this psychic Priest Ray that did a love spell and broke every spiritual distraction from my marriage. A day later my husband started showing me love and care even better than it used to be, he’s ready to talk things through and find ways for us to stay happy. It’s such a miracle that my marriage can be saved so quickly without stress. You can also contact him for help by email [email protected] or WhatsApp: +12133525735 and you can also visit his website: https://psychicspellshrine.wixsite.com/my-site

- Friday, October 13, 2023
2014315119

Contact Dr Ozigidon if you have been trying to conceive, I never thought I'd be writing this message but after 5 years of infertility and nearly lost my marriage due to not being able to have a child after suffering from PCOS and my TUBES ARE TIED, and severe endometriosis and scanning, I was told that IVF was the only option. This was something we could not afford and had almost given up hope of becoming a parent. A friend of mine recommended Dr Ozigidon to me and persuaded me to contact him, I finally contacted him and he made a spiritual breakthrough to get me pregnant with his powerful spell, within 2 weeks I was pregnant (naturally!!!) and my tube was untied as instructed by this powerful sorcerer. Now! I gave birth to healthy twins in February. I am writing this testimony for those women who are facing the same challenges or even more, depressed with no light at the end of the tunnel. Give Dr Ozigidon a try to help you solve your problem, and hopefully you'll have the same success that I have had. His email address ([email protected]) . Call or Whats-App him +2349054750112. I wish you all happiness in your marriages

Maria Willie - Thursday, June 29, 2023
2013654893

I'm so excited my broken Marriage been restored. My ex lover is back after he left me and our kids for another woman. I was so happy to meet Dr Trust and how he helped many people to bring their lover back so I contacted him to help me too. That was how Dr Trust helped me to bring my lover back. A big thank you to Dr Trust because I never thought my ex lover would be back to me so quickly with your spell. You are the best and the world greatest. If you are here and you need your Ex Lover back or your lover moved to another woman, do not cry anymore, contact this powerful spell caster now. Here’s his contact: Email: [email protected] WhatsApp: +14242983869 Facebook Page: https://facebook.com/trustspelltemplez

Maria Willie - Thursday, June 29, 2023
2013654893

I'm so excited my broken Marriage been restored. My ex lover is back after he left me and our kids for another woman. I was so happy to meet Dr Trust and how he helped many people to bring their lover back so I contacted him to help me too. That was how Dr Trust helped me to bring my lover back. A big thank you to Dr Trust because I never thought my ex lover would be back to me so quickly with your spell. You are the best and the world greatest. If you are here and you need your Ex Lover back or your lover moved to another woman, do not cry anymore, contact this powerful spell caster now. Here’s his contact: Email: [email protected] WhatsApp: +14242983869 Facebook Page: https://facebook.com/trustspelltemplez

Please login to comment