Psychologists have long faced the tension between keeping minimal or detailed records of therapy. Minimal or lean records are more protective of patient privacy if the records are sought by insurers or other third parties, such as attorneys. Detailed therapy records, on the other hand, can facilitate continuity of care if the patient must transfer to another psychologist, can remind the psychologist of details that may be important later in therapy, and may assist the psychologist in the event of a licensure complaint or lawsuit. 

For example, a lean record might indicate that the psychologist is working with the patient on interpersonal issues at work complicated by his diagnosis. A very detailed record might document that the patient is having trouble being sexually intimate with his partner and is instead compulsively watching pornography at work due to continued distress related to childhood sexual abuse. Those who keep very detailed information might put this in the same record with the clinical information (what we refer to as a “combined record”) or in separate psychotherapy notes.

The recent emergence of Risk Adjustment (RA) Audits under the Affordable Care Act (ACA) has brought this tension back to the forefront. Psychologists with patients who obtain coverage through insurance exchanges are most likely to experience these audits, and it appears that those with Medicare Advantage clients may face very similar audits. While we do not yet know whether insurance carriers outside of the exchanges will be conducting similar audits, we can expect that more psychologists will receive audit requests once the practice begins in 2015.

As explained in a prior PracticeUpdate article, the APA Practice Office of Legal and Regulatory Affairs recommends that psychologists who anticipate receiving these audit requests either keep a lean clinical record or, if they want to record sensitive details, keep separate psychotherapy notes, as defined by the Health Insurance Portability and Accountability Act (HIPAA). For psychologists who want or need more detail, keeping separate psychotherapy notes allows them to record sensitive information and other particulars from therapy while protecting this information from third parties. This practice also creates a separate clinical record (PDF, 208KB) that is more appropriate for, and easier to share with, insurers and other health care providers.

Underlying this recommendation is the threshold question: Do you want detailed therapy notes in the first place? This article briefly touches on some considerations to help you answer that question.

What a record should look like

What does an ideal patient record look like? There is no such thing as an ideal patient record and therefore no answer to this question. However, guidance is available from a number of sources that can help you decide how to document your interactions in a manner that fits your style (often influenced by experience and training) while protecting patient information.

The APA Ethics Code also offers some direction. Standard 6.01 says that records should be kept in a way to “(1) facilitate provision of services later by them or by other professionals, (2) allow for replication of research design and analyses, (3) meet institutional requirements, (4) ensure accuracy of billing and payments, and (5) ensure compliance with law.” 

The American Psychological Association’s Record Keeping Guidelines (PDF, 84KB), revised in 2007, speaks to the tension between the minimal and detailed record approaches. Guideline 2, specifically, directs psychologists to be mindful of certain things when deciding how detailed to make a record, including the client’s wishes, third-party contracts and state laws and regulations.

  • Client wishes. It might be helpful to have a discussion upfront with the client about what type of information gets recorded in the clinical record. Talk to the patient about the balance between protecting their privacy interests and needing to ensure continuity of care and justify the medical necessity of care. 
  • Third party contracts. When you accept Medicare, insurance or payment from other third parties, review that company’s or agency’s guidance on the documentation it expects for psychotherapy, both for the overall record and for individual sessions. Some insurers only provide general record keeping guidance aimed primarily at physicians, which is not specific to mental health. If that is the case, we recommend you send the company a written request for the record keeping it expects from psychologists. 
  • State laws and regulations. Some state laws and administrative rules specify what the licensing board expects to see in a patient record (for example, Florida Administrative Rule 64B19-19.0025 delineates the exact information to be documented). Other jurisdictions are less specific. For example, the Texas Administrative Code merely requires that psychologists create records in a manner that ensures continuity of care, and that impressions and tentative conclusions should be identified. 

Finding the appropriate balance

We are not aware of any state laws or rules requiring psychologists to record sensitive details of therapy. It really boils down to the psychologist’s philosophy regarding record keeping and the patient’s wishes. When determining how much detail to record, it might help to ask whether the detail is necessary, or at least helpful, to the way you practice. Using the example at the beginning of this article, will you remember sensitive details that may be important to your patient’s treatment if you don’t write them down — for example his inability to have sex with his partner, viewing pornography in the workplace and the childhood sexual abuse? 

As you create the record, write the information assuming that the patient will eventually see it. This approach will minimize any embarrassment or discomfort if and when the patient reviews his or her record.

If you choose to record sensitive details of therapy and have patients whose files might be audited, we suggest that you keep separate psychotherapy notes. This will maximize your patient’s privacy protection, while simplifying your response to the audit: You just provide the basic clinical record and not the separate psychotherapy notes. As noted in the PracticeUpdate article about risk adjustment audits, APAPO has been able to persuade some of the insurers conducting these audits to let psychologists who keep a “combined record” just extract the minimum information necessary for the audit from records that also include sensitive and sometimes extensive details of therapy. This solution protects patient privacy, but the extraction process could be tedious and time-consuming.

If you keep a minimal record, be sure to have enough details to withstand scrutiny by a third-party payer or by the licensing board, and to allow a subsequent provider to continue therapy. For example, the record should, without going into unnecessary detail, support the diagnosis you have provided and the medical necessity of your treatment. 

Please note: Legal issues are complex and highly fact specific and require legal expertise that cannot be provided by any single article. In addition, laws change over time and vary by jurisdiction. The information in this article does not constitute legal advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.