Thanks to everyone who took my Progress Notes Survey.  I clearly struck a nerve: 499 of you answered the survey, and left more than 850 comments, sharing your stress, frustration, anger, and feelings of inadequacy around this area of your practices.  This is the sixth in a series of articles where I report on the survey results (if you missed the first five articles, click here)

Today’s article focuses on whether clinicians who answered the survey say they have been asked for records, and how confident they in their notes if they were asked to produce them.

Are notes being requested?

In my previous reports on the survey results, I reported that of the 499 survey respondents, only 21% of respondents stated they had NEVER experienced a records request, a documentation review, or a request for a treatment review.  Read that carefully.  This means a vast majority of respondents — 79%– have faced one or both of these often-stressful situations.  Clearly, this means that even if you who don’t work with insurance, you need to be ready for treatment reviews and requests for records by outside agencies.  (To get your records up to snuff, check out my webinar on What’s Missing From Your Charts: Writing Great Progress Notes)

How confident are clinicians about their notes?

I asked respondents how confident they would feel in the quality of their notes and charts if their received a records request from an insurance plan, licensing board, ethics committee, disability worker, or legal representative.  The answers are below.

What does this mean?

Only 5% of the respondents felt “very confident” about their notes, and 25% said they were “fairly confident.”  This means that 70% of respondents had one or multiple concerns about their records.

16% said their notes are not easily readable, so a records request would be stressful. 25% said they had some concern about the quality of their notes.  51% said they only felt their notes were just  “adequate,” so a records request would be stressful.

And finally, 2% of respondents said they did not keep notes at all, so a records request would be very stressful.  It is important to note that not keeping notes is strongly discouraged, as it could be considered “unprofessional conduct,” and violates most state laws, ethics codes, licensing laws, and health plan requirements.

The Take away

Since almost 80% of therapists had received a records request, these should be viewed as a normal part of working with insurance plans.  Yet only 5% of survey respondents said they felt very confident about their notes.  Because of this, it is clear there is a need to learn to build our confidence in our notes, and to write notes and treatment plans as if a reviewer might read them, in a manner that will please health plans.  Then, we can be prepared and calm when a record request comes. To get the training you never got in grad school on documentation, check out my webinars What’s Missing From Your Charts: Writing Great Progress Notes” and my training “How to Write a 10 Minute Treatment Plan.”