What is the Value of Charting in Psychotherapy Practice?

What is the Value of Charting in Psychotherapy Practice?

  • There is no empirical evidence to support assertions made by Healthplan payers and EMR vendors that the inpatient style and detail of a comprehensive record is an appropriate standard for outpatient psychotherapy.

  • Manualized treatment is not empirically supported as more effective than non-manualized treatment. While manual‐based treatment may be attractive as a research tool, it should not be promoted as being superior to non-manualized psychotherapy for clinical practice.

  • First and foremost a psychotherapist must chart in a way that informs and benefits care as it begins, unfolds, and ends. The second purpose is to document those appropriate services were provided in a manner that can measure outcomes, patient satisfaction, and is useful to physicians treating a patient for associated problems.

  • To create chart notes that meet the information expectations, and needs of all potentially interested parties, is impossible given the constraints of private psychotherapy practice.

  • There is no empirical evidence that patients or the public benefit from disclosure of sensitive, intimate, personal or private information required in writing by interests external to psychotherapy. There are no studies that examine the benefits and harm caused by psychotherapy chart notes.

  • Courts of law have repeatedly supported the position that psychotherapy cannot work without privacy and confidentiality.

  • Parties such as health plan payers, judicial systems, managed care businesses, and other healthcare providers who are not part of psychotherapy treatment often assert they have a rightful interest in what takes place in psychotherapy sessions, even though the interest they assert does not contribute clinical value or enhance the quality of treatment.

  • There is no empirical “underpinning” to suggest there is a link between “good clinical practice” and “level of record keeping.”

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