Documentation is an integral component of the delivery and reimbursement of Healthcare Services.
Psychotherapy Note VS Progress Note: what’s the difference?
A Psychotherapy note is a detailed account of what is discussed in session with the client, typically more private than a progress note.
Progress notes are part of the medical record and contains more objective data that is shared with other providers and insurance companies.
Requirements for documentation vary by profession, state, and other factors of the like.
Some common requirements include:
- Name and Indentifier (e.g. Chart ID, Date of Birth, etc.)
- Date of service, including the start and end time of the session
- Provider’s Name
- Place of Service (In Office, Telehealth, Home, etc.)
- Client Presentation and Mental Status
- Interventions Used and Response
- Treatment Plan, Goals, and Progress
DOCUMENTATION:
SOAP Notes
S: Subjective
O: Objective
A: Assessment
P: Plan
S: Subjective
this is where details are recorded about what the session is about and what is being discussed with the client
- what they’re experiencing or their presenting problem
- How thier experience is effecting their life
- History and events that provide supporting detail to the issues they’re experiencing
O: Objective
This section is focused on facts and figures. These facts and figures are reached by methods of clinical observation and assessments that are standardized
- a clients behavior, affect, mood, presentation and appearance relating to mental status.
- What interventions were used and how they responded
- Results from standardized assessments (like the GAD-7)
A: Assessment
Here, you bring together the information that was collected through the previous sections (S and O) to create a clinical summary of the data.
- What DSM-5 diagnostic criteria is being met according to the data above and what can be ruled out?
- Explain how the data recorded points to the likelihood of your diagnostic impression.
- Describe how their current symptoms relate to the diagnosis.
P: Plan
Where the information you have gathered and assessments you have conducted are used to create a plan of how to improve facilitate your client’s progression towards their goals.
- Outline actions and interventions you and the client intend to work on in order to help them reach the goals you have set together.
- Current progress so far and how you can further facilitate progress together.
DOCUMENTATION:
DAP Notes
D: Data
A: Assessment
P: Plan
D: Data
The focus of this section is to gather details and information regarding the client’s current issues and what they are experiencing, as well as data from clinical observation and standardized testing. This is done to create a clinical assessment and treatment plan
- Clinical assessment of clients behavior, affect, mood, response to intervention, etc.
- History and events related to current issues
A: Assessment
Here, you bring together the information that was collected through the previous sections (S and O) to create a clinical summary of the data.
- What DSM-5 diagnostic criteria is being met according to the data above and what can be ruled out?
- Explain how the data recorded points to the likelihood of your diagnostic impression.
- Describe how their current symptoms relate to the diagnosis.
P: Plan
Where the information you have gathered and assessments you have conducted are used to create a plan of how to improve facilitate your client’s progression towards their goals.
- Outline actions and interventions you and the client intend to work on in order to help them reach the goals you have set together.
- Current progress so far and how you can further facilitate progress together.