“I can’t wait until I open my private practice and never have to do paperwork again!” There are many misconceptions about opening a private practice but this one in perhaps the biggest. Paperwork is the arch enemy of many a clinician but sad to say, going into private practice will do little to solve them. Now don’t get me wrong, I have less paperwork in private (ok, small not for profit) practice than I ever did before but I still have my share. Although I no longer have to do an expense report (because no one will pay me back for it anyway), I no longer have to do a mileage report, quarterly reports etc. Private practice still has many paperwork related items. “If I don’t take third party payments I don’t have to even have charts or take notes.” This is perhaps in 2nd place for comments when I am doing a training, lecture, etc. on private practice design and implementation. I am not sure where this one came from either but I suspect some kind of narcotic was involved. If you are practicing in the field you have documentational requirements. Period. This is for many reasons but let’s start with a few of the biggies. While laws may vary from state to state, all clinical professionals are required to document their work. This is not just a requirement for insurance companies although they do tend to require more than the laws would require, it also serves as evidence for the services you performed should you ever face a malpractice complaint or be subpoenaed. As professionals we have a responsibility to help our clients get better and this includes the need to work with other professionals during treatment and post treatment as needed. Here good documentation in key. Years ago I was in a position where I was asked to review the files of a clinician as part of an ongoing court case (I was to be an expert witness for the case). She was a doctor from an Ivy League school and had a solid reputation for the most part but recently her abilities had been called into question. My job in part was simply to review her charts (the ones related to the case only) and to proffer an opinion based on the records, whether or not it appeared best practices had been employed. On the day the documents arrived for review I was shocked to find little more than modified billing sheets. There was a lack of consent forms, releases and the session notes amounted to little more than the date of a session, what they were billed and what was paid. While I do not know the outcome of the case (as an expert witness I testify and the case ends for me; I am not concerned with the outcome as I have no side in a case and simply provide expert opinions/ assessments) but I cannot fathom any positive outcome for the therapist in this case. Though she may have performed great therapy, once called into question her documentation did nothing to help her show that she provided quality services, due diligence or anything more than billing. This blog today is short but hopefully to the point: EVERY clinical professional regardless of placement needs to have quality paperwork. Please avoid this issue by becoming aware of the paperwork requirements, implementing quality control measures and use due diligence. Sample documentation can be found on my website under “Com Counseling Review” and as always on the ACA website under the counselors/private practice pointers.
Warren Corson III (Doc Warren) is a counselor and the clinical & executive director of a community counseling agency in central CT (www.docwarren.org).