Ideally, clinical notes provide a clear accounting of time with a client. Anyone reviewing documentation, including an auditor, should be able to assess what occurred during a session, have an idea of the general treatment plan, know the status of the client's state of mind, and determine the next course of action in the treatment.

Clinical documentation serves two primary roles. Foremost, clinical documentation is a tool that guides the clinical process and aids in measuring outcomes; secondly, it provides the content required for clients' clinical chart, also known as the medical record. Medical records are legal documents and are protected under the Health Insurance Portability and Accountability Act (HIPAA). As such, great care should be taken in the format and content of each and every note or document. The American Medical Association describes the medical record as a "key instrument used in planning, evaluating, and coordinating patient care in both the inpatient and the outpatient settings. The content of the medical record is essential for patient care, accreditation (if applicable to the practitioner), and reimbursement purposes. Medical records (charts) should detail information pertinent to the care of the patient, document the performance of billable services, and serve as a legal document that describes a course of treatment" [1]. Although behavioral health professionals are not physicians, they are providers of care and are subject to the same kind of guidelines and scrutiny to which physicians have grown accustomed.

For the general practice therapist, the most applicable regulatory governing bodies are the insurance companies with whom they are contracted to provide services. Providers participating in an insurance network (e.g., managed care organizations [MCOs] and health maintenance organizations [HMOs]) are contractually obligated to comply with specific standards and regulations, usually outlined in the contract. Some of these standards may incorporate the relevant requirements set forth by the applicable licensing board as well. Standards and regulations, while administered and monitored through the insurance company, are derived from much higher levels of governance, including federal, state, and local governments and accreditation agencies.

Agencies such as the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS) are responsible for the development and oversight of guidelines based on policy, law, and standards of practice. In turn, state levels of governance, such as State Departments of Health and Human Services, Public Regulation Commissions, Departments of Insurance (DOIs), and Behavioral Health Services Departments (BHSDs) are responsible for administering these guidelines at the state and local levels and ensuring compliance with the federal guidelines.

Clinical chart audits are one way regulatory and governing bodies monitor adherence to the standards they set forth. Chart audits typically occur at the service level and are usually conducted by the quality and compliancy departments within the MCO/HMO. When an audit is conducted, the organization will measure how well the standards have been met using an audit tool. Audit tools specify the areas an audit will address, including assessment of the physical environment of a facility or office; quality of documentation, including thoroughness, adherence to HIPAA standards, organization of the chart, format of documentation, and whether or not the specific treatment reported in the clinical documentation meets medical necessity guidelines; and finally, financial and billing information.

Clinical chart audits are one way regulatory and governing bodies monitor adherence to the standards they set forth. Chart audits typically occur at the service level and are usually conducted by the quality and compliancy departments within the MCO/HMO. When an audit is conducted, the organization will measure how well the standards have been met using an audit tool. Audit tools specify the areas an audit will address, including assessment of the physical environment of a facility or office; quality of documentation, including thoroughness, adherence to HIPAA standards, organization of the chart, format of documentation, and whether or not the specific treatment reported in the clinical documentation meets medical necessity guidelines; and finally, financial and billing information.

Medical necessity is a guideline developed by the quality and compliancy department within an MCO/HMO and is often referred to as a level-of-care guideline. Although there is no federal definition, and only slightly more than one-third of states have any regulatory definition of medical necessity, it is most commonly found in individual insurance contracts that are defined by the insurer and hold primacy in most determinations [3]. These guidelines are developed as tools to assess whether or not the treatment provided is in accordance with the treatment need for a specific level of care.

Medical necessity is a guideline developed by the quality and compliancy department within an MCO/HMO and is often referred to as a level-of-care guideline. Although there is no federal definition, and only slightly more than one-third of states have any regulatory definition of medical necessity, it is most commonly found in individual insurance contracts that are defined by the insurer and hold primacy in most determinations [3]. These guidelines are developed as tools to assess whether or not the treatment provided is in accordance with the treatment need for a specific level of care.

There are several guiding rules or principles under HIPAA. The most familiar of these are regarding privacy, security, and breach. An important principle under the Privacy Rule is that of "minimum necessary," a term that applies to various aspects of disclosure. According to the U.S. Department of Health and Human Services, "The Privacy Rule generally requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, protected health information to the minimum necessary to accomplish the intended purpose" [4].

Although this statement does not specifically discuss the content of clinical documentation as part of its definition, it is reasonable to assume the principle extends to content as well. While regulatory bodies define the general content areas required in clinical documentation, the specifics of the content should adhere to the "minimum necessary" principle in order to comply with HIPAA principles. Clinicians should write chart notes that they would feel comfortable sharing with the client. Conversely, information referring to risk of any kind must be well documented. The key is to state facts and to write in an objective and neutral manner. A few guidelines to keep in mind: only keep one set of notes, avoid subjective statements/opinions, and use clients' own words whenever possible.

Mental health assessments are usually the first clinical document resulting from an initial session with a client. A thorough mental health assessment gives the clinician a global perspective of the problem and provides the basis for formulation of diagnoses or a hypothesis of dysfunction. It is a tool used to collect information about a client's presenting symptoms and complaints and a method for identifying early treatment needs and creating a treatment plan. It can also aid in rapport building and assessing a client's history and current level of risk. The mental health assessment is an important part of the medical record and the basis from which all other clinical documentation will develop. In some cases, an initial assessment is required by the MCO/HMO for prior authorization of services, depending on the care setting.

The structure of the assessment tool guides clinicians to ensure key areas are evaluated. Information may be gathered from a variety of sources: a referral source, the client during the interview, collateral information received from other providers, and family members, when appropriate. Observations of a client's appearance, emotional expression, and affect, and his or her reactions or interaction with the therapist during the interview should be noted as well.

During any session, but especially in the initial assessment interview, a heavy burden rests on the clinician to assess for risk and have a willingness to act on behalf of clients who are in imminent danger of harming themselves or others. Assessing for risk in the initial sessions allows the clinician to ensure the immediate safety of the client but also to obtain a baseline of risk behaviors, triggering events or situations, and level of coping.

A comprehensive assessment reveals areas of clinical focus for treatment and identifies barriers to treatment. Treatment needs are typically symptom- or behavior-based and are the seedlings that eventually become the treatment plan. Barriers to treatment are equally important when evaluating treatment needs. If a client has transportation problems, is unable to make his/her co-payment, has a cognitive impairment, or is from a vastly different culture than the therapist, these factors may impede treatment progress. While therapists cannot be responsible for the immediate needs of their clients (such as transportation), the identification of these barriers can be treatment opportunities, allowing clients to develop the skills needed to locate, access, and utilize supports. By identifying and addressing these barriers early, and strategizing with the client on ways to address them, the potential for positive therapeutic outcomes is dramatically improved.

Treatment planning is the ability to develop a comprehensive understanding of a client's situation, needs, barriers, and ability to make therapeutic gains and applying this information to measurable outcomes. The level of complexity in treatment planning varies based on the treatment setting and client needs.

Presenting Problems

This section provides an overview of the current issues and gives the first clues about symptoms, precipitants, or circumstances; why the client came to therapy; and what he/she hopes to gain from therapy. Asking questions like "What brought you to therapy at this time?" and listening for key issues like "I'm not sleeping well" will support treatment planning and diagnostic formulation.

Communication and Cognitive History

Communication is fundamental to the therapy process. Without it, engagement and therapeutic impact/change can be difficult to measure or assess. Noting any organic, cultural, or language barriers to communication helps to identify any potential impediments to treatment. If a communication or cognitive barrier is identified, this should be included in the treatment plan with an appropriate intervention. For example, a deaf client may require an interpreter or a referral to a therapist who can communicate via sign language. Cognitive history might include head trauma, dementia, learning disabilities, or other processing issues. If collateral information has been received from other providers about the clients' cognitive history, include this as well.

Strengths

Asking clients about their strengths and reflecting on observable ways in which their strengths can build trust in the therapeutic relationship. It also helps to reveal clients' coping strategies, which can be built into the treatment plan. If a client is unable to identify strengths, this may in itself be an aspect of treatment and built into the treatment plan.

From the initial presenting problems, start to develop an idea about which symptoms need clarification. For example, initial complaints of poor sleep might indicate symptoms of anxiety or depression. It is important to clarify the symptom category and determine which symptoms are the most distressing to the client; this becomes a starting point for diagnostic formulation and treatment planning. After the primary symptom(s) are identified, gathering measurable information about each symptom is helpful. These will be used later in treatment planning, but it also gives more insight into the level of distress the client feels in relation to the symptom. Measurable data includes duration, frequency, and intensity of symptoms. Assess for triggering events/situations and impact to functional areas (e.g. relationships, school, work, etc.). For example: Client reports feeling anxious for the past year with symptoms of rapid heartbeat, sweating, feeling fearful that something bad is going to happen, feeling faint, and racing thoughts. Client reports this occurs at least three times per week, typically at home, and when it occurs, she is unable to leave the house. Client states the symptoms seem to be triggered when her spouse goes out to drink with friends. On a scale of 1 to 10, symptoms at their worst are rated a 9. In this case, measurable goals may be to reduce anxiety/panic symptoms from a 9 to a 5 in intensity and from three times per week to not more than one time per week. Subjective goals may include increasing the client's insight into the triggering event and improving coping with mindfulness techniques.

The revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) updated the definition and some of the criteria in the substance use disorder category, now referred to as Substance-Related and Addictive Disorders. In addition to assessing for substance use using these criteria, assess for other kinds of addictions as well. When substance use or addictive behaviors are identified, treat them similarly to symptoms by collecting data that includes measurable content. At a minimum, gather data for the following items:

The primary risk factors assessed for in the initial session usually include suicidal ideation, suicide attempts, self-harming behaviors, and threats to harm others. Additional risk behaviors can include engagement in dangerous or illegal activities, such as drinking and driving or going to a hotel with a stranger to buy drugs. Risk behaviors are almost always a focus of treatment when they are identified, more so when behaviors are active and pose a risk to the client or others. Gather and record as much data about the risk behaviors as possible, including, but not limited to, age of onset, frequency, duration, intensity, method(s), interventions/consequences, and triggering event or circumstances. For example: Client reports, "I cut myself when I am feeling really stressed out." Client states cutting behaviors began at 12 years of age, following her parents' separation. Client has engaged in cutting with a razor on upper arms and inner thighs for the past five years at least three times per week and states, "I just can't stop now…It helps me feel better." Client denies any medical interventions and states that her parents are unaware of the behavior because she hides it well. Further assessment can determine current stressors/triggers leading to self-harming behaviors.

Always include initial diagnoses on the mental health assessment. In 2013, the a new version of the DSM was released, resulting in changes to diagnostic criteria. The five-axis structure has been eliminated. The Global Assessment of Functioning (GAF) scores have been replaced by more specific scales built into the diagnostic criteria. For example, a depressive diagnosis is now rated as mild, moderate, or severe based on the number of symptoms presented or identified. In addition, Z-codes are integrated into the diagnosis when the code identifies a specific factor that is either the focus of treatment or has an impact on treatment. The basic format for documentation of the diagnoses may be structured as follows: primary diagnosis as focus of treatment, personality factors, medical factors, and psychosocial factors (Z-codes). For example, a diagnostic formulation might be written as: F32.1 Major Depressive Disorder, single episode, moderate; F11.20 Opioid Use Disorder (moderate); F60.3 Borderline Personality Disorder; E11 Type 2 Diabetes; T74.11XD Spouse or Partner Violence, physical, confirmed, subsequent encounter. Also, note that diagnostic codes have also changed and are now congruent with ICD-10-CM codes typically used by medical practitioners. To ensure the most up-to-date diagnostic information, the DSM-5-TR should be used.

Areas included in an MSE may vary depending upon treatment setting. However, there are nine generally accepted categories of assessment on the MSE: appearance, motor activity, speech, affect, thought content, thought process, perception, intellect, and insight. Additional categories may include mood, cognition, judgment, impulse control, activities of daily living, ambulation, appetite, and sleep. Points to consider in each of these categories include [5]:

Diagnostic formulation refers to the analysis of presenting information applied to a set of specific criteria that allows a working supposition to emerge and thus treatment to begin. For the midlevel clinician, it is not uncommon for little attention to be given to the process of diagnostic formulation in the academic setting. It is an egregious misrepresentation to presume the only purpose of developing diagnoses is to bill insurance. While it is true that to bill for a therapeutic session/interaction, a diagnosis must be included, this is, of course, not the ultimate goal of diagnosis. Without a working theory or hypothesis of the presenting issues, there is no basis for treatment to occur.

The field is changing rapidly, and midlevel clinicians are expected to step up to the treatment standards to which medical practitioners currently adhere. Evidence of this lies in the DSM-5-TR, the diagnosis codes of which are congruent with codes in the ICD-10, which are used by medical practitioners.

Developing a diagnostic picture requires more than identifying a set of symptoms, although this is a starting point. Understanding the full diagnostic picture requires an ability to identify important factors impacting symptoms, which is why there are so many assessment categories in a mental health assessment.

That said, there is no denying that diagnostic formulation is complex; a foundational understanding of the mechanics/technical aspects is required to be successful. Although studying the DSM-5-TR is recommended, the following will give a foundation to the process of diagnostic formulation.

Start with the identified objective information collected from the mental health assessment. This includes specific symptoms and their onset, duration, frequency, and intensity; the results of the MSE; and collateral information from other providers. After the primary symptoms are known, the DSM-5-TR will aid to further home in on a primary diagnosis. Other information from the assessment may be used to support or disprove a diagnostic theory based on the criteria noted for the proposed diagnosis. Always take into account culture, areas impacted, overall level of functioning, medical factors, and other psychosocial factors. A combination of objective and subjective factors can be the difference between a diagnosis of major depressive disorder versus an adjustment disorder with depression, each of which has different treatment plans or approaches.

Treatment planning begins at the first encounter with the client. During the initial mental health assessment and diagnostic formulation, identifying symptoms and a focus for treatment emerges. To some degree, treatment planning does not vary significantly from one level of care to another, but the specific interventions are dependent on the level of care and the practitioner. In other words, the treatment plan in an inpatient setting will attempt to reduce symptoms of acuity and the underlying cause, such as depression or anxiety. However, in this case, the intervention will be one of a short duration with a focus primarily on stabilization. In an outpatient setting, when acuity is stable and the duration of engagement is expected to be longer, the treatment plan, while also focused on symptom reduction, will focus on developing coping skills.

Progress notes are the threads that tie treatment together. A good progress note addresses progress of current treatment goals, identifies new goals, assesses the client's response to treatment, includes new information not previously identified in the mental health assessment, notes changes in diagnoses, and ultimately represents evidence of treatment. As with the mental health assessment, progress notes should include the client's demographic information, date of service (with start and end time), description of services, and location of service (e.g., office, school, hospital). In the event documentation occurs at a time other than at the time of service delivery, include a notation of the late entry (including entry date/time) along with the date service occurred. Organizing a progress note can be done in several ways. One way is using the Data, Assessment, and Plan (DAP) format.

Generally, the format of the discharge summary will include the client's demographics, date of discontinuation of treatment, reason for discontinuation of treatment, a summary of treatment provided and the client's overall response (with specific reference to treatment goals), and notation about whether goals were met and to what degree. If treatment goals were not met, this should also be noted. Include any change to diagnoses and medications being taken at the time of discontinuation of treatment. Finally, include details about referrals made and any aftercare plans that were discussed and are part of the client's plan of action post-treatment.