We partner with our neurodiverse community to provide trauma-informed and strengths-based counseling services.
Documentation Best Practices
General
All entries in the record must contain the author’s signature or electronic identifier with title (if applicable) and degree.
Make sure to document everything that is clinically indicated, including phone calls, emails, and text messages.
Assessment
All incoming clients must have an assessment on file. The assessment must include a full biopsychosocial. Much of this information will be captured on the intake assessment form if thoroughly completed. Be sure to include a mental status examination (try to include a minimum of 3 elements)
Your first session should be a 90791 code. For insurance clients, you must diagnosis on the first session. The diagnosis may be tentative. Ensure there is a clear thread between your assessment and diagnosis.
Treatment Plans
Treatment plans must be on file for all clients and include a dated signature from the licensee and the client/legal representative/guardian.
Treatment plans must be updated annually at a minimum. Make sure to include a review date in your plan.
You should update the treatment plan if you update the diagnosis and/or focus of counseling.
Treatment goals must be specific (follow SMART goals format).
Treatment plans must specify methods/interventions.
Please note that our EHR (Simple Practice) does not include a “review date” on treatment plans, which is a requirement from the Arizona Board of Behavioral Health Examiners. Please make sure to manually include a review date on your treatment plans (typically next to each objective in the plan).
Good Faith Estimate
The No Surprise Act was created to ensure out-of-network clients are not given “surprise” invoices following treatment. Part of the No Surprise Act is the Good Faith Estimate, which informs clients of expected charges for treatment.
For out-of-network and/or private pay clients, we are required to provide a Good Faith Estimate prior to initiation of services.
You may access the Good Faith Estimate in Simple Practice by following these instructions.
You likely will not be able to estimate the total number, duration, and frequency of sessions prior to meeting with the client. Therefore, a suggestion is to complete a Good Faith Estimate for your intake assessment, then create a second Good Faith Estimate based on your clinical recommendation for the total number, duration, and frequency of sessions.
Clinical Notes
Submit notes within one business day of the session. According to the Board of Behavioral Health Examiners, contemporaneous documentation means notes are signed within ten days.
Update the time of service to reflect the actual start and end time of the session.
If counseling services were provided, include whether the counseling was individual, couples, family, or group (write this in the first line of the session note).
You must “lock” notes in order to sign and timestamp.
It is essential that your notes clearly establish the "medical necessity" of the provided care. This means:
Demonstrating "medical necessity" involves confirming a genuine clinical requirement and ensuring that the services administered are an appropriate response.
"Medically necessary services" refer to healthcare services that a healthcare practitioner, guided by sound clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its associated symptoms. These services must meet the following criteria:
Align with widely accepted medical practice standards.
Be clinically suitable in terms of type, frequency, extent, location, and duration.
Be deemed effective for addressing the patient's condition.
Not primarily serve the convenience of the patient, physician, or other healthcare provider.
Not incur greater costs than an alternative service or sequence of services that is equally likely to yield comparable therapeutic or diagnostic results for the patient's condition. In this context, "generally accepted standards of care" refers to standards rooted in credible scientific evidence published in peer-reviewed medical literature, generally acknowledged by the pertinent medical community. It should also be consistent with recommendations from physician specialty societies and the perspectives of physicians practicing within the relevant clinical fields, among other pertinent factors.
The note should include any relevant diagnoses.
The level of care administered should be appropriate to meet the client's needs.
The likelihood of the intervention or service being effective should be considered.
Documented evidence of the treatment or service's efficacy should be provided.
Services should be administered efficiently, and with logical intensity, frequency, and duration to prevent wastefulness.
In the notes, you should include the following information:
Safety/risk assessment: Document any clinical risk factors, particularly if there is a risk of self-harm or harm to others. This documentation should occur during each session, along with the patient's presentation and clinical response.
Functional impairment: Describe how the patient's symptoms affect their ability to function in various aspects of life, such as work, school, home, and relationships with family and friends. Explain why ongoing care is necessary based on these impacts.
Interventions: Detail the specific interventions implemented and the rationale behind them, including why they were chosen.
Response: Record the patient's response to the interventions.
Symptoms: Document the patient's symptoms and their progression.
Therapeutic interventions: Specify the therapeutic techniques or approaches used during the session.
Date of the next session.
Frequency of sessions, based on your clinical recommendation.
Justification for 60-minute sessions, including evidence supporting the medical necessity for this duration ("A 60-minute session is medically necessary as evidenced by...").
In 2016, the American Medical Association (AMA) clarified how to use certain CPT codes for therapy sessions. They specified that codes 90832, 90834, and 90837 are meant for individual therapy sessions. These codes should only be used for family sessions if a family member occasionally joins an ongoing individual therapy session. In such cases, the family member acts as a visitor/collateral to the individual treatment or may receive a summary of the individual's progress. Moreover, for these family sessions, the client who is the primary focus of the individual sessions must be present for most of the family session. As a result, CPT code 90837 should not be used for ongoing family or couples therapy sessions. Instead, you should use CPT codes 90847 for couples or family therapy when the client is present and 90846 for such therapy when the client is not present. Both of these codes represent 50-minute sessions.
For individual sessions with a visitor/collateral, make sure to use the visitor’s consent form.
Children of divorced parents
Pursuant to ARS 36-2272: Except as otherwise provided by law or court order, no person, corporation, association, organization or state-supported institution, or any individual employed by any of these entities, may procure, solicit to perform, arrange for the performance of or perform mental health screening in a nonclinical setting or mental health treatment on a minor without first obtaining the written or oral consent of a parent or a legal custodian of the minor child. If parental consent is given through telemedicine, the health professional must verify the parent's identity at the site where the consent is given.
In Arizona only one signature is required whether they are married or not. Best practice would be to get both parents to sign. It also only takes one parent to request that you seize services whether they are the ones that consented or not.
Obtain custody/decision-making court documents and/or agreements for any case involving children of divorced parents.
Couples counseling
The intervention must emphasize the identified client.
The note should demonstrate medical necessity for the identified client. Family counseling
Family Counseling
Create separate files for each family member if you are conducting therapy with any of the members.
Use the visitor’s consent form if family members will be present as a support during the session, but not receiving individual and/or family therapy.
Telehealth documentation
Include the mode of session, whether interactive audio, video, or electronic communication, and verify the client’s physical location during the session. If telehealth, you must indicate which platform was used.
Example: “Therapist met with the client for an individual telehealth counseling session via the Simple Practice platform. The client was located in-home (address on file) for the duration of the session.”
You must be licensed in the state in which the client is located. Check the other state’s licensing laws for information about conducting sessions out-of-state.
Language in Documentation
Documentation should be clear, precise, respectful, and inclusive, supporting the therapeutic relationship and adhering to ethical standards and regulations.
Professional Titles and Roles
Use specific professional titles such as "therapist" or "clinician" instead of generic terms like "writer" to clearly denote the author's role. This practice aids in distinguishing between different professionals within multidisciplinary teams and enhances clarity in shared documentation.
Precision in Terminology
Always spell out medical and psychological terms fully to prevent ambiguity and misunderstanding. For instance, clearly differentiate between "Bipolar Disorder" and "Borderline Personality Disorder" by avoiding abbreviations like "BPD." This precision supports effective communication and understanding among care teams and clients.
Affirmative and Inclusive Language
Choose language that affirms and respects clients' identities and experiences. For example, use "Autistic" rather than the acronym "ASD" to acknowledge the individual's experience more affirmatively. Similarly, employ gender-neutral terms such as "parent," "caregiver," "client," "spouse," or "partner" to ensure inclusivity and respect for all gender identities and family structures. This approach promotes a welcoming and supportive environment for every client.
Confidentiality and Anonymity
To protect client confidentiality, especially in contexts where documentation might be shared or need to be redacted (e.g., legal requests, audits), minimize the use of names within the body of clinical notes. Instead, refer to clients by their roles or relationships, or use pronouns after the initial mention. This strategy reduces the risk of confidentiality breaches and simplifies the process of redacting personal information when necessary.
Cultural Sensitivity and Competence
Embrace language that is culturally sensitive and demonstrates an understanding of the client's background and experiences. Acknowledge and respect cultural differences in health beliefs, practices, and communication styles, and reflect this understanding in your documentation. This commitment to cultural competence fosters trust and strengthens the therapeutic alliance.
Telehealth Therapy
When considering telehealth for mental health counseling, there are several scenarios where a client might be deemed inappropriate for this mode of treatment. Key considerations include:
Danger to Self or Others: If a client exhibits signs of being a danger to themselves or others, telehealth may not be suitable. In such cases, immediate in-person intervention or hospitalization might be necessary to ensure safety.
Severe Psychiatric Symptoms: Clients with severe psychiatric symptoms, such as those experiencing acute psychosis, severe depression, or mania, may require more intensive, in-person care. Telehealth might not provide the necessary level of observation and immediate response required.
Lack of a Stable Environment: For telehealth to be effective, clients need a private, secure, and stable environment. Those who lack such an environment, perhaps due to homelessness or living in a chaotic household, may not benefit as much from telehealth services.
Technology Limitations: Clients who do not have access to the necessary technology, such as a reliable internet connection and a private device, may not be able to engage effectively in telehealth.
Cognitive Impairments: Individuals with significant cognitive impairments or difficulties in understanding or using technology might struggle with the format of telehealth and would benefit more from in-person services.
Legal and Ethical Constraints: Certain legal and ethical constraints might limit the use of telehealth in some cases. For example, if a client is in a jurisdiction where the therapist is not licensed to practice.
Preference and Therapeutic Alliance: Some clients may simply prefer face-to-face interaction and find it hard to establish a therapeutic alliance through a screen. The lack of non-verbal cues and physical presence in telehealth can impact the therapeutic relationship for some individuals.
Complex Trauma or Abuse Situations: In cases of complex trauma or ongoing abuse, the lack of physical presence and direct observation by the therapist can be a limitation. This is especially true if there's concern about the safety or privacy of the client during telehealth sessions.
Substance Use Disorders: While telehealth can be effective for some individuals with substance use disorders, those in acute withdrawal or needing detoxification might require in-person care.
Discharge planning
A discharge plan could include follow-up as necessary, outreach documentation, crisis numbers, and/or an opportunity to return to the provider in the future.
Discharge planning should be discussed and documented throughout treatment.
Note that 60 days without service would suggest to insurance that an episode of care has ended, meaning you should complete a discharge summary at this time. If you reinitiate services, you should complete a new intake assessment.
Consents
Always make sure to obtain a dated and signed informed consent for treatment from the client or their legal representative before providing any form of treatment. Additionally, if there's any change in information that might impact the client's consent for treatment, be sure to obtain updated consent.
Before recording audio or video of the client or allowing a third party to observe the treatment provided to the client, it's essential to obtain a dated and signed informed consent for treatment from the client or their legal representative.
Include a dated signature from an authorized representative of the behavioral health entity on the consent forms.
Please note that our EHR (Simple Practice) does not include our dated signatures on our consent. According to the Arizona Board of Behavioral Health, your signatures are necessary in addition to signatures from the clients. You will need to download the consents, sign and date them, and re-upload them to maintain compliance with the board.
When working with minors, ensure that you've confirmed their guardianship status and that you have proper consent in place. This may involve checking for consent from separated or divorced parents or having copies of court orders that establish sole custody and the authority for medical decision-making.
Communication with primary care and/or other specialists
Request permission to communicate with the primary medical practitioner. Primary medical practitioner communication may occur after the initial evaluation, as a result of a significant change in member status, after a psychiatric evaluation if medications are initiated or treatment/diagnosis warrants such communication, or after significant changes in medication. Evidence of communication could be documentation of a phone conversation, email correspondence, or a letter.
Clients may also decline to consent.
Other behavioral health specialists may include psychiatrists, ancillary providers, treatment programs/institutions/facilities, or other behavioral health providers or consultants.
Disability Letters
The Arizona Board of Behavioral Health appears pretty consistent that clinicians should not be offering specific opinions on legal matters. Additionally, clinicians should also not be providing opinions on disability matters. The board states: “…the practice of professional counseling/social works states a clinician is to assess, appraise, evaluate, diagnose, and treat clients.” Please keep this in mind as we frequently receive requests from clients to complete documentation on their behalf (this includes ESA letters, which the board has also indicated are outside our scope of practice). If these requests are made, please inform clients that the board has prohibited these activities for counselors and social workers, and direct them to a medical professional.