How Confident Are You in Your Progress Notes?

Progress Notes Survey Results (Part 6)

 By Barbara Griswold, LMFT

(November 18, 2019)

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)

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 Writing Great Progress Notes)

This final survey question 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.

Only 5% of the respondents felt “very confident” about their notes.  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 this would be stressful. 25% said they had some concern about the quality of their notes.  51% said they only felt their notes were “adequate,” so a records request would be stressful. 2% said they did not keep notes at all, so a records request would be very stressful [note: not keeping notes is strongly discouraged, as it violates most state laws, ethics codes, licensing laws, and health plan requirements].