Timely Documentation

All licensed therapists have an ethical, legal, and professional responsibility to maintain accurate and timely client records. This is true regardless of where you are practicing. In alignment with this standard, therapists in the Rula network are required to sign & complete all service notes within 48 hours of the service completion. Please review this article for best practices regarding documentation style, time management, and work-life balance.

What happens if I don't complete documentation within 48 hours? 

  • Insurance claims may be denied or delayed. This could result in your clients not being able to access the continued treatment they need, or approved for the additional services you have referred them for. 
  • Rula’s reputation with payers and clients is also at risk if we can't produce documentation when requested. Remember, clients have a right to request their medical record at any time. 
  • Incomplete medical records can be used against you to support allegations of professional negligence and fraud. That old adage of, “if it's not in the chart, it didn't happen”, is true, especially in the presence of risk. 
  • If we notice a pattern of late documentation, you may hear from one of Rula’s Clinical Quality Specialists (CQS). Your designated CQS will partner with you to provide any support you need as you complete outstanding notes, and establish a strategy to complete notes on time going forward. 
  • Documentation submitted beyond 48 hours may result in a provider being paused to new clients or terminated from the Rula network.

What are the common barriers to getting notes done within 48 hours of the service?

We’re therapists, but we're also human. Challenges such as time management, documentation style, and work-life balance are commonly reported as contributing to late or missing documentation. So how does Rula support you when you find yourself in these situations? Let's talk through some strategies and tips. 

Time Management

  • Be mindful of session duration and maintaining a firm stop. Sessions that repeatedly run over the scheduled time make it difficult to reserve any dedicated time for completion of documentation. It can be helpful to block your schedule between sessions to avoid numerous back-to-back sessions. This allows for documentation time (and of course a break for you!) in between sessions.
  • Schedule a specific time of the day to complete notes. Some providers block out an hour at the end of the day, or maybe the first hour of the next morning before they start a new day's sessions. 
  • Try concurrent documentation - meaning documenting the session in real time during the visit with the client. While this practice is not for everyone, there can be value in having the note template pulled up in session and jotting down key terms such as specific symptoms, comments related to functional impairment, and so forth as it provides a “head start” on the note that you're going to be submitting. 

Documentation Style

Depending on your prior training, you may find yourself with a documentation style that results in very lengthy (and time consuming) progress notes, making it easy to fall behind. If this is something you struggle with, try focusing primarily on what content is required in a commercial payer world. So what do you focus on?

  • Specific symptoms - After stating the client’s diagnosis, it is essential to add what symptoms that client is experiencing. This may look like, “Client reports continued anxiety - uncontrollable worry, often easily annoyed, irritable, and increased avoidance of other people.”
  • Functional impairment - Document how your client’s symptoms are getting in the way of their daily life, relationships, work, etc. The goal here is to identify not just that they're experiencing symptoms, but how those symptoms are impeding their quality of life.
  • Clinical intervention(s) that are in direct response to the stated symptoms and functional impairments.
  • Client's response to the interventions that you used. Was the client open to the interventions? Did they refuse to participate? 
  • Plan - What's going to happen between this session and the next scheduled session? How will the client make progress toward their identified treatment goals? Describe that here.

If your style is to capture more detailed clinical information than the above, you could consider the use of “psychotherapy notes,” in addition to what you enter in AMD. As a reminder, psychotherapy notes are the notes that are recorded often by hand on paper during the session to capture quotes, clinical detail, but is separate from the official medical record and falls under the “psychotherapy notes” HIPAA exemption. Use of psychotherapy notes is a great way to make sure you're keeping track of that rich clinical information that you may want to reference later on, but there's no need to embed that in the service note in AMD.

Like any new behavior, this may take time and practice. Try it out with one or two clients to begin and see how it feels to write more concise, targeted notes. How much time is it saving you? As you increase that practice over time, it often gets easier!

Work-Life Balance

It’s important to engage in regular reflection of your current capacity, whether that's emotional capacity, time capacity, or your own mental health needs and gauge your ability to fulfill your ethical and legal obligations as a licensed therapist, which includes timely documentation of services rendered. If you find yourself falling significantly out of compliance with documentation requirements due to the stressors or obligations you are managing in your personal life, consider some of the options below to ensure your needs, and your clients, can be met:

  • Pay attention to your caseload size: In the Rula network you have the autonomy to control the volume and populations of clients you treat at any time, and you should make adjustments as needed. You can temporarily pause yourself to new referrals or modify your schedule to reflect what you can realistically commit to. 
  • Hold firm boundaries with clients regarding accessibility to you, your schedule, and your scope of practice. You are not on-call. When feeling overwhelmed by client needs, it is important to connect them with other support resources that are available outside of their treatment with you (such as 988). You also may need to consider connecting them with a different therapist as part of a re-match process if their treatment needs are beyond your scope and adding to your stress. 
  • Take a temporary break from client care or reduce your case load so that documentation is more manageable. If you find yourself in this situation, contact your provider success associate and/or Support to talk through some options. We truly value your needs as a therapist, and want you to take care of yourself!

 

Please know, Rula’s Clinical Quality Team is also here to support you with your clinical practice, including meeting 48 hour documentation expectations. If you would like additional support, check out options for connecting with the Clinical Quality team here or email them directly at quality@rula.com. Therapist to therapist - we’re here for you!

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