I frequently hear from therapists who feel they were never taught to keep good client records.  What do the plans expect?  I’m going to tell you.  But don’t panic if your records are a tad less detailed — I’d wager few of us meet these requirements.

However, we should all try to take steps toward writing clinical notes that meet these criteria, as one never knows when a records review might be requested, whether you are in-network or out-of-network for insurance plans.  Yes, whenever a client submits a superbill to a health plan, it opens your treatment and your notes up to scrutiny by their insurance plan.  In addition, good records may be necessary to support client disability, worker’s compensation, or legal actions, or to defend you in an ethics complaint.

While each health plan has their own list of what they expect in provider documentation, typically required elements are modeled after the documentation requirements from the Center for Medicare and Medicaid Services.

Common Health Plan Note Requirements

1. Service start and end times (ex. “1:05 to 1:55 pm” — this is important to back up the billing time you billed for!). These times should naturally vary from session to session.  Health plans do not find it credible if each week you report the same session start and end times.
2. Patient’s name on each page, names of others in session, and their relationship to the patient
3. Service date on each page
4. Service type (e.g. ex. diagnostic assessment, individual, family)
5. Whether the session was in-person, by phone, or via video.  If phone or video, document the client’s location.
6. Problem statement (including diagnosis)
7. Support for medical necessity of treatment
8. Service rendered, including therapeutic interventions (e.g., “insight oriented therapy” is not enough — details about the session’s treatment approach and techniques are needed)
9. Person-centered detail such as behavior description or quotes
10. Patient observation (e.g. mental status examination is required at intake, and may be required in each session).
11. Summary of progress (or lack thereof) toward goals; lack of progress should result in change in care pla

Treatment Plans