Documentation and HIPAA
Photo credit: National Cancer Institute (Unsplash)
There's an old adage in social work education: "if you didn't write it down, it didn't happen." The need for documentation is apparent for many reasons: a log for billing and payment purposes, a record for possible legal requests, staying organized, and more. All wise businesses keep a thorough account of their interactions--therapy practices and social service agencies are no exceptions. There are many ways that therapists document sessions, and these methods must be held to a set of standards through The Health Insurance Portability and Accountability Act (HIPAA).
HIPAA sets the guidelines for the way that your Protected Health Information (PHI, such as diagnoses, treatment plans, medications, therapy notes, etc.) is stored and shared. Providers are legally required to securely store your PHI, provide you access to it upon your request, and get your consent to share it with anyone else. All information related to mental health and therapy is considered PHI and therefore falls within these guidelines.
Typically at the onset of medical and mental health treatments, new patients are provided with a series of forms that should include Informed Consent and other office policies, likely including a HIPAA form. This form discusses the office's intended use for your information, including but not limited to billing your insurance company.
There are several reasons why your therapist may ask you to sign a Release of Information or HIPAA form. It is often beneficial for providers to collaborate on your case and discuss aspects of your care; this is particularly relevant if you have both a psychiatrist and therapist who do not work for the same company. If you have a case management component to your care, providers may require Releases for referrals to set you up with the next phase of your therapeutic journey. Additionally, therapists for children may wish to coordinate with schools.
A widespread documentation tool is an Electronic Health Record, or EHR. These may also be referred to as EMRs, or Electronic Medical Records, depending on the setting. In private practice therapy, platforms like Simple Practice, Therapy Notes, and others provide user-friendly interfaces to keep an electronic, secure record of the health data from a patient or client's therapeutic interactions. These platforms are HIPAA-compliant and may have additional features for billing, scheduling, and more. They may also have a component for clients to interact with and pay their bill.
When it comes to actual note-writing, clinicians commonly use 1 of 2 standard formats: DAP or SOAP. DAP stands for Data Assessment Plan and basically covers the content and observations of a session, the clinician's assessments, and a plan for next steps. SOAP notes are very similar, including Assessment and Plan as their last 2 components, but SOAP notes break down the Data into 2 parts: Subjective (reports of experiences) and Objective (factual). DAP and SOAP notes are pretty interchangeable and are usually just a matter of preference.
Regardless of the platforms or notation styles a company utilizes, documentation is extremely important. Therapists in training should practice writing thorough notes and have their supervisors critique them. For people engaged as clients in therapy, I hope this was helpful in teaching you about your rights and the usage of your private Protected Health Information.
