[Transcript] Episode 439: What Info is Actually Part of the Client’s Record

 

Evan Dumas

You’re listening to Group Practice Tech, a podcast by Person Centered Tech, where we help mental health group practice owners ethically and effectively leverage tech to improve their practices. I’m your co-host, Evan Dumas.

 

Liath Dalton 

And I’m Liath Dalton, and we are Person Centered Tech.

 

Liath Dalton 

This episode is brought to you by Therapy Notes. Therapy Notes is a robust online practice management and electronic health record system to support you in growing your thriving practice. Therapy Notes is a complete practice management system with all the functionality you need to manage client records, meet with clients remotely, create rich documentation, schedule appointments and bill insurance all right at your fingertips. To get two free months of Therapy Notes as a new Therapy Notes user go to therapynotes.com and use promo code PCT.

 

Evan Dumas 

Hello and welcome to Episode 439: What Info is Actually Part of the Client’s Record?

 

Liath Dalton 

This is a both simple and complex question, right? Because on the sort of face value of it, you might think, well, just clinical information or medical information, but what exactly meets that, that definition? And obviously that the answer is consequential, because part of clients’ rights are to have access to their medical record, their healthcare info and record, and that it should be complete when they are accessing it or doing a records request. And that’s meaningful and impactful for a multitude of reasons, including continuity of care and quality of care, and so making sure that when you are creating and maintaining clients records and when you are releasing client records, that it contains everything it needs to is important.

 

Evan Dumas 

Yeah.

 

Liath Dalton 

So what actually goes into a client’s record and what doesn’t? And I’ll share that this podcast episode topic was prompted by a recent question from a group practice, in our Group Practice Office Hours related to complying with the records request and wanting to make sure they included everything necessary, and wondering if some of the intake questionnaires were part of it. And what about client texts and emails and voicemails? And what if those client texts, emails, and voicemails weren’t specifically about clinical info and were more just related to scheduling and logistics or payment? Is that something that needs to be part of the record?

 

Liath Dalton 

So we thought this was a good time to just provide some some clarity around this important topic. Now in terms of HIPAA and state law, because both have something to say about what is in a medical record, HIPAA is looking at a designated record set. That’s the terminology that they use. I’ll include a link in the show notes to their definition of designated record set, and then your state law is actually the primary authority as to what exactly comprises a client’s medical record. But it’s pretty standard across the states, and I haven’t seen real variation there.

 

Liath Dalton 

But it’s always important to note that the ultimate authority on what a medical record contains, and must contain, it is going to be your state law, so the anything that relates to a client or patient’s health care is part of their medical record, and that includes not just any intake questionnaires and documentation, but any communications, including those emails and texts and voicemails, whether or not the content is clinical or medical in nature. Anything that is related to their receiving health care services is part of their record, and should be, for ease of your maintenance, and being able to properly comply with recordsrequests, you want to be including that documentation of emails and texts and summaries of voicemails or phone conversations in the client’s record.

 

Liath Dalton 

So a little bit about the the rationale for why these pieces are included in in the record and need to be released when a records request is received. Evan, what are a couple good, good reasons and and rationales for, for why this broad scopeof information is necessary?

 

Evan Dumas 

Oh, yeah, well, so much of it can be medically relevant. So a couple instances of it are in the intake questionnaire they put some information that you are going towant to address. That you’re going to want to either address an intake or in session, or say they, you know, maybe reveal signs of abuse during the intake questionnaire, because they feel a safe place to put that. And then when you talkto them on the phone, they’re under duress, and so they say, nope, everything is fine. And so you go, Oh, that’s conflicting information. That’s therapeutically relevant. I should note that.

 

Evan Dumas 

Similarly in text. So some people say, Oh, the five minute running late thing. That’s not I don’t need to note that, because that’s just regular, normal stuff. Well,say they were an always on time client, and maybe they’re coming to you for drug addiction or other things, and all of a sudden they’re running five minutes late, 10, 20, minutes late. This might be a sign of relapse. This might be therapeutically relevant, something for you to note, or, you know, maybe they justput a whole bunch of really therapeutically relevant stuff in the text. Well, then, of course, you’re definitely going to want to note that. But all of these little things that we take for granted or leave out can all be necessary and should be noted in the record for for just future use.

 

Liath Dalton 

Exactly. Because any interactions and communications are things that are going to be relevant to informing your diagnosis, assessment, treatment, interventions and care, and therefore that’s contextually relevant to the client’s record and needs to be included. Because in part, that then informs the continuity of care, or kind of ability for continuity of care and quality of care that they receive from other healthcare providers who aren’t going to be able to provide the same level of care or quality of care if they are missing key contextual pieces of information that are relevant to, you know, diagnosis, assessment, etc. So that’s why it is broader than just, you know, the lab reports or actual assessment instruments and so on.

 

Liath Dalton 

It goes without saying, of course, that progress notes are one very vital component of what a client’s record is comprised of. And want to draw attention to something that there can be a lot of confusion around. Because there is a big distinction between progress notes and psychotherapy notes. And psychotherapynotes are separate from and distinct from progress notes, and basically they are protected from release. They aren’t considered part of a client’s medical record under HIPAA, and that’s federal, but only if psychotherapy notes are protected under state law. And there are a number of states where psychotherapy notes are not protected. California is an example of one such state.

 

Liath Dalton 

So it’s important to note that if you keep psychotherapy notes, first and foremost,find out if your state law protects them or not. And if it is protected, then that needs to be noted in your HIPAA Notice of Privacy Practices that is provided to clients, and then it needs to be kept distinct from the client’s medical record. We have a whole episode, actually, about psychotherapy notes, and we’ll include that in the show notes section as well.

 

Liath Dalton 

Because basically, there’s this interesting aspect of the definition of psychotherapy notes that means basically, if they contain any of the sorts of details, any of the things that are in a designated record set under HIPAA or medical record under state law, anything related to assessment or diagnosis or interventions, that takes it out of qualifying as being a psychotherapy note. So we need to apply the precise definition of psychotherapy notes to how they are created and maintained.

 

Liath Dalton 

If we are availing ourselves of psychotherapy notes, a better way to think about them is kind of as process notes and related to the provider’s own processing. Butbasically, anything that goes in the client’s actual medical record needs to not also appear in the psychotherapy notes. Two very, very different things. So do, docheck out that additional clarification around psychotherapy notes. Any other pieces you would add about documentation and what a client’s record is comprised of Evan that could come up?

 

Evan Dumas 

Yeah, I just want to give the tiny little shout out to the fear a lot of clinicians havewhen they do release all these extra notes, that they didn’t think were part of the record is that, you know, the feeling isn’t for you if you’re nervous about this. It is that our, you know, our schooling probably didn’t teach us to write notes saying that the clients may see them. And this is a whole separate issue for, oh, what gets documented and oh, did I write it in a way that will cause client harm, etc?

 

Evan Dumas 

And we have some wonderful trainings on that, on Rethinking Notes, that’s the title of it. And so really normalize this with your clinicians. When you talk to them about, hey, note these extra things, and if they go, oh, I don’t know, then say, oh, okay, we have some training on how to rethink notes, how to do them in a way that’s more conducive to your client-clinician relationship, and also include these extra things, because here, here are the reasons why.

 

Evan Dumas 

So you may, you may run into that sort of challenge from folks when you start enforcing these, these, these new policies. So just know that that’s there. But you know, we can only work with what we learn when we learn it, and that’s, that’s part of the process.

 

Liath Dalton 

That’s a really important point. Evan and I think that kind of historically, the way that a lot of mental health providers, in particular, like in a very different category to kind of pure medical providers, have approached documentation, clinical documentation has been from this sense of these are kind of private notes. They’re the clinician’s, not the client’s, right? And that’s something that the 21st Century Cures Act also referred to kind of in in layman’s terms, as the Open Notes Rule sought to address, which is that clients that are receiving health care have a right to information about the healthcare that they receive and everything related to that healthcare, and what informed their diagnosis and treatment and so on, and that they have access to that, in part, to equip them and give them autonomy when it comes to obtaining healthcare services from other providers as well.

 

Liath Dalton 

So the record and access to it and its contents being thorough and accurate, are actually instruments of client care itself. And so we need to be approaching documentation from from that angle. And as Evan said, part of the way that documentation is done is then going to be informed by that, in terms of thinking, okay, when I’m doing documentation, clinical documentation, and have an awareness that a client has rights of access to it, and likely, at some point will avail themselves of that access. How does that impact the way that I am documenting things?

 

Liath Dalton 

And this isn’t it’s to say that you then omit things or sugarcoat things. It still must be accurate. But there, I think, is the different level of care and consideration thatgoes into actually creating documentation when that awareness of client access is really present, so supporting your team around this approach to documentation and really centering that the documentation is in and of itself, part of the client’s care, is a good way to approach it and and an opportunity to help strengthen your your team’s clinical skills as well.

 

Liath Dalton 

So hopefully this is is useful, and if you are thinking, oh, wait, we haven’t been doing diligent documentation in our EHR, for example, of textual communications, and emails, and voicemails and and all of that, or we have, but not for everything, not including those scheduling or kind of pure logistics-seeming communications, start from where you are, right? Implement that going forward. Train your team on the requirement of that being being done in the first place, and help support them in managing that in a efficient and effective way and for any communications.

 

Liath Dalton 

Thankfully, if you are using HIPAA friendly email, all of the emails that have ever been sent should be retained within that and able to be accessed and added to records. And hopefully there’s also some history of textual communications as well, depending on what phone service provider you’re using. So whatever you currently have documentation of and access to, you can add that to records. So it’s a little bit of a course correction there, but that obviously, especially in a group practice, or large group practice in particular, can be a bit of a burden, and we don’t want you taking on something that is too onerous in that regard.

 

Liath Dalton 

So a lot of times, people will have a little bit of a panic about not having full sets of all the required information in every client record when they receive the kind ofclarifying guidance on what needs to be in a client record and say, oh no, what do I do now? Our response then is you do not have to make this massive project of going through and updating every client’s record right now. The way that you want to tackle that is to do it on a client by client basis, and use the sort of metricfor what takes something to highest priority for doing that, is going to be clients that have provided an ROI and want a records release. Then those are the ones that you go through the process to make sure that it is, you know, current and comprehensive and contains all the necessary info that it does.

 

Liath Dalton 

So I don’t want this to be causing any panics and and crazy projects for folks. Butit’s more about going forward, making sure that the records are including everything that they need to, and then having a basis, a rubric for how to make complete and and current any records that aren’t in that state. And, and how to manage that.

 

Liath Dalton 

Hopefully this has been helpful. Do check out the additional resources in the show notes, and we look forward to chatting to you next week.

 

Evan Dumas 

Yeah, talk to you next week, everybody.

 

Liath Dalton 

This has been Group Practice Tech. You can find us at personcenteredtech.com. For more podcast episodes, you can go to personcenteredtech.com/podcast, or click podcast on the menu bar.