Over the years, we have seen many therapists lose cases due to inaccurate or incomplete charting.  Sometimes an entire lawsuit can hinge on the notes, or lack of notes, contained in a patient=s chart.  Every 10 years or so, the theory of notes and charting changes.  At one time, therapists preferred not to chart too much and believed Aless was better.@  Then, attitudes changed and mental health professionals began to chart everything under the sun and would write novellas for every appointment with a patient.

 

You never know how important notes or lack of notes are in a chart until you are on trial.  Imagine sitting in the witness chair and the plaintiff attorney has a 12' x 12' blow up of a note you wrote five years ago.  When he asks you to explain the note, you are at a loss of words or perhaps cannot even read the note.  Many plaintiff attorneys and their experts base their entire case on the medical records and notes of the attending therapist.  You should pretend that every note you write will be read by a plaintiff=s expert and will need to be explained to a jury.  Many therapists never realize the importance of charting until they are sued and have to explain each and every note in their chart, or lack thereof.  Although mental health professionals often feel that the clinical notes in the patient=s chart are for the Aclinician=s eyes only,@ a better perspective on charting is that any note that is made in the chart will be seen by everyone.

 

It is important to accurately record all significant events and comments made by the patient and others in order to document all necessary information.  The patient=s chart should reflect the basis for your clinical judgment decisions regarding the patient=s care. Our recommendation is to chart a standard SOAP note or variation thereof each time a therapist sees a patient.  Medications must be charted even if you are not the professional who is prescribing those medications.  Informed consent issues, suicide ideation, and specific stressors should always be charted as well as the diagnosis of the patient.

Phone Calls

     Questions often arise whether phone calls from the patient in between visits should be charted.  Most clinicians do not chart phone calls from patients mainly because they are answered when there is a free moment and the patient=s chart is usually not available when the phone call is returned.  We have seen many cases where the issue of what is said during a phone call becomes very relevant at the time of trial.  From a risk management point of view, I always suggest that phone calls from patients be charted in the patient=s file.  This is especially true when you consider that many lawsuits are filed years after the phone call in question and the therapist will not have a good recollection as to what was said during that phone conversation. 

Please Don=t Write This In My Chart

     Many times patients tell the clinician Aplease don=t write in my chart the following information I=m about to give you.@  The clinician is always placed in a therapeutic dilemma when they agree to not chart certain items the patient tells them.  Over the years, we have seen patients request that the following issues not be charted by their therapist: abortions, drug abuse, pregnancies, HIV, STD and extramarital affairs. Remember, it is up to the clinician to decide what should be charted or not.  It is not the decision of the patient to determine what should be charted. If it is important to the underlying stressors, diagnoses or treatment then the information should be charted.  My advice on whether charting is complete and accurate always goes back to the following statement: AIf you die tomorrow, could another therapist pick up your chart and know exactly what is going on with the patient?@  If the answer to that question is Ano,@ then your charting is not sufficient.   

Suicidal Ideation 

Many times clinicians write Ano S/I@ to indicate that the patient did not have suicidal ideation at the visit.  Although the charting of Ano S/I@ may be sufficient, from a risk management point of view is better to put down the specific information used as a basis for the clinical judgment that the patient was not having suicidal ideations or was not a risk for immanent suicide.  Are there facts in your notes to support your clinical findings that the patient was not suicidal?   

Keep Your Notes Legible 

Although it is easy to say all therapy notes should be legible, our experience is that many times they are not.  There is nothing more embarrassing than a clinician being cross-examined at trial or deposition and that same clinician is unable to read his or her notes.  We once had a case where a doctor read his notes to indicate that the patient was complaining of Amarijuana@ headaches when, in fact, the note indicated it was Amigraine@ headaches.  We have seen cases where a patient died in a hospital and the discharge note stated the patient was discharged home in good condition.  Imagine explaining that note to the jury.  Often, jurors believe that sloppy note taking is an indication of sloppy psychotherapy practice.  Over the years we have seen clinicians putting wrong dates, wrong names and wrong diagnoses in the patient=s charts.