Assumptions that Charting Requirements Always Align with Patients’ Best Interests are Not Valid

A Healthy Contracts Position Paper

Based on a thoughtful critique of how external influences - ranging from insurance companies’ mandates to professional standards - shape documentation practices in ways that do not necessarily align with the best interests of patient care.

Research Findings on Psychotherapy Documentation

MRI found no research which demonstrates that the volume and detail which Healthplans and regulatory bodies require has a positive impact on behavioral and/or mental health services, patient satisfaction, and outcomes.  In fact, the demands for detail may cause more harm than good.  The scarce few studies we found, as well as expert opinions, question the assumption that detailed assessments, treatment plans and progress notes contribute to patient satisfaction and better outcomes. For example…

• Andrea Neal’s Dissertation (2003): This study showed that there was no significant difference in therapeutic outcomes between patients who received therapy with structured, written treatment plans and those who did not. This suggests that an enforced routine of creating detailed treatment plans may not have the intended positive impact on therapy outcomes.

• Michael King’s Observations (2014): King points out the lack of empirical support linking detailed record-keeping with improved therapy results. His critique highlights a gap between clinical practice ideals and the empirical evidence supporting them, suggesting that much of the expert advice on record-keeping may be based on unverified assumptions.

• Systematic Review by Femke Truijens (2018): This review found no empirical evidence to support the superiority of manualized treatments over non-manualized treatments. This challenges the assumption promoted by many institutional bodies that manualized, standardized treatment approaches are necessary for effective therapy.

 The Multiple Purposes of Psychotherapy Charting

The litany of reasons why psychotherapy notes are kept, illustrate complex interplay of clinical, organizational, legal, and reimbursement factors. For example…

1. Clinical Use: Chart notes serve as a historical record that helps therapists track the progress and regressions in a patient’s mental health journey, aiding in treatment adjustments and understanding. This would be true in a multidisciplinary treatment institution such as hospital system. Not an individual or group practice setting.

2. Organizational Needs: In some settings, particularly those where services are provided by a team rather than an individual therapist, detailed records help coordinate care among various providers. However, a weak link in the chain of care can through the entire effort off track.

3. Reimbursement Requirements: For many therapists, particularly those in systems involving insurance, detailed documentation is crucial for reimbursement. This documentation must often satisfy very specific insurer criteria to justify the costs of therapy. That criteria is almost always hidden and expensive for providers to challenge.

4. Legal and Regulatory Compliance: Various laws and regulations may dictate the content and extent of medical records, including assessments, treatment plans, and progress notes. Compliance with these legal requirements are used protect therapists from future legal disputes which are rare, and may have a deleterious impact on provider practice willingness to treat complex and severe cases. However, Federal Minimum Necessary Guidelines require that providers control and limit what information is released based a “right to know”.

 Concerns Over Extensive Detailed Charting

There are potential downsides of excessive documentation:

1. Impact on Therapeutic Relationship: If too much focus is placed on documentation, it can disrupt the natural flow of therapy sessions. Patients may also become hesitant to share sensitive information if they know it will be extensively recorded and potentially reviewed by others. However, ethical informed consent can cause patients to distrust the provider and to withhold information.

2. Privacy and Confidentiality Issues: With detailed records, there is an increased risk of personal, private and sensitive patient information being accessed by unauthorized parties, especially in the case of data breaches, inappropriate access, or subsequent legal demands for records.  Patients may not understand that when information that is irrelevant to treatment is placed in a chart it can cause harm in the future. Patients and providers do not always remember what was said or how it was understood.

3. Resource Allocation: The time and effort spent on detailed charting could instead be directed towards direct patient interaction, which might provide greater benefits to patient care. Provider can waste 30 to 40% of their time creating chart notes that nobody needs or has time to read. Healthplan require it, but how does that help patients who can’t get appointments. If providers we allowed to document the minimum necessary information, that would free up more than 1 hour per day. access to care could increase by more than 10%.

 Call for Reevaluation and Immediate Changes in Documentation Practices

Prevailing sentiments suggest that a reevaluation of current documentation practices within the field of psychotherapy may be a good idea. Documentation should be purposeful and beneficial to therapy, rather than a bureaucratic exercise to satisfy external requirements. This reevaluation could lead to a reduction in unnecessary paperwork, allowing therapists to spend more time focusing on patient care and less on administrative tasks.

There is a need for a balanced approach to psychotherapy documentation; one that fulfills necessary legal and professional obligations while remaining flexible enough to prioritize effective patient care and the therapeutic alliance between patients and providers.  After all, it is the therapist-patient relationship that matters first and foremost.  Without that, nothing works.