Dear Barbara, I recently took your training on how to write great progress notes. I am now writing awesome notes, which feels great! But what do I do about my old notes, that are just plain crummy, or the ones that are missing? – Embarrassed in El Paso

Dear El Paso,

Thanks for writing. I get this question all the time, and it’s a great one. First, let’s put aside the shame. I’d wager that every therapist who is reading this has some embarrassment about their notes. Maybe your notes have never been good. Maybe you never knew what to write. Maybe there were periods where life was particularly difficult, so notes just took a back seat. It happens to all of us.

But now things have changed. I’m delighted you found my documentation training helpful, and that you are taking the steps I outlined so that you are now habitually writing great notes. But what should you do about the old notes that weren’t so good, ones you wish you could rewrite, or those notes that are totally missing?

I’m not sure there is a “right answer” that applies to all situations. But let’s look at your options:

1. Do nothing about your old notes. I call this the “Go Forth and Sin No More” option. I know, you are shocked I might even suggest this as an option. But in some cases, especially if your audit risk is low, and you haven’t the faintest idea what you talked about with that client in that particular session, you are going to end up spending a lot of time creating notes without supporting information. Again, I’m not saying this is the best option, but I like to put all options on the table.
2. Go back and try to play catch up with ALL your unfinished, poor, or missing notes. This may be the best option, as you may feel much better to have a note for each session. But depending on how many notes are affected, this can take days or months to catch up, and again, you may not have much information to base your note on (we’ll discuss how to ethically enter an old note later).
3. Selective catch-up. In this option you play catch-up only on the cases where notes are most likely to be requested. Less time-consuming than Option #2, it may seem less overwhelming, yet can still reduce your anxiety about your most concerning cases. Of course, this still requires time – sometimes a lot.
    
   With this option, consider each case individually, but consider working on the charts of clients:
   • where you are in-network with the health plan – start with clients from health plans that audit most frequently, such as Medicare, Medicaid, and UHC/OPTUM, followed by Blue Cross
   • with personality disorders, and those who have expressed anger at you
   • who could be involved in a legal struggle, or have a litigious background
   • who are high-risk (suicidal, etc.).
   • who are minors, and whose parents could request the chart

Four questions to help you decide which path to take

When choosing a path, ask yourself:

1. How high is my audit risk? That is, what is the likelihood that my records will be requested? Look through the bullet points in #3 above. If those don’t really apply to you, your audit risk may be very low.
2. Did you write anything down during or after the session? Playing note catch up is difficult without this.
3. Calculate how long Option #2 would take. Figure out how much time it takes you to convert whatever you currently have (if anything) and write a formal session note for one old session, or to enter your session-day scribbles into your Electronic Health Record (EHR). Then multiply this by how many notes you must write and divide by 60 – this will give you many hours this project will take. So, if it takes you 8 minutes to write a note, and you need to catch up with 30 notes, this should take 8 x 30 or 240 minutes, or 4 hours. If it feels doable, you may want to take Option #2, and schedule that amount of time somewhere in your calendar to catch up with old notes. If it doesn’t feel doable, you may want to choose Option #1 or #3.
4. Do an anxiety check. Imagine you choose Option #1. How do you think you will you feel? Then imagine Option #2 and Option #3. Your anxiety level may be the most important factor in choosing your path.

But isn’t it fraud to rewrite a note?

Yes, it can be considered fraud to make a late note appear as if it was written on the day of the session. So don’t rewrite notes and try to hide that it was rewritten, or create a brand new note and try to hide that the note was added later. If you add information to notes, ethically you must state what was added and when. If the note is written from scratch more than a few days after the session, be honest – put the session date AND the date that the note was written or added to your EHR.

If you took “draft notes” at the session but never formally wrote them up, you can use this. Add a statement somewhere in the final note saying something like: “This note written on [date] based on handwritten notes taken during the session/on the day of the session” or “this note entered into the EHR based on notes taken during the session/on the day of the session.”

If you do play catch up, some final tips

1. Make your current notes a priority. Don’t spend so much time playing catch up with older notes that you neglect today’s notes.
2. Start first with the most recent notes and go backwards. More recent notes are the most likely to be requested.
3. Want to catch up, but can’t get motivated? My colleague Dr. Maelisa McCaffrey of QAPrep.com runs a Paperwork Catch-up Book Camp where she leads group catch up sessions with other clinicians – plus she does individual consultations. Contact her to and get support – click here.