What are Progress Notes?
An Overview of Progress Notes as They Are Utilized in Documenting Mental Health Treatment Records
Michael Griffin, Esq.
CAMFT Staff Attorney
September 25, 2020
10:00 am – 11:30 am Cost:
Licensed Chapter Members
1.5 CEUs for $25
1.5 CEUs for $30
$10 (no CEUs)
A zoom link will be emailed to registered participants followed by a Course Evaluation
CE Certificates will be sent to you after payment for the course and your returned Course Evaluation
This workshop presentation will be recorded and available from 09/28/20 until 10/19/20 for those who are unable to attend the live presentation. You will be able to register for the recorded event and obtain CE credit for the workshop after the live workshop has occurred.
This 1.5-hour course, including Q and A, is intended to provide a brief overview of the topic of “progress notes,” as they are utilized in documenting mental health treatment records.
To help therapists understand the primary legal rules governing the provision of treatment via minor's consent.
Measurable Learning Objectives
Upon completion of this workshop, attendees will be able to:
• Describe 3 or more specific functions/purposes for progress notes.
• Explain how progress notes are relevant to the requirements expressed in California Business and Professions Code, 4982. (v), which requires therapists to “keep records consistent with sound clinical judgment, the standards of the profession, and the nature of the services rendered.”
• Explain how progress notes are relevant to the ethical standards concerning client/patient records, as expressed in §5.3 of the CAMFT Code of Ethics.
• Explain the difference between “progress notes” and “psychotherapy notes” as they are defined by HIPAA.
1. WHAT ARE PROGRESS NOTES?
Progress notes are brief, written notes in a client ’s/patient ’s treatment record, which are produced by a therapist as a means of documenting various aspects of the treatment provided, including, the nature of services rendered, and the necessity and efficacy of such treatment.
2. ARE THERE KEY LEGAL AND ETHICAL STANDARDS FOR DOCUMENTATION?
The fundamental legal and ethical standards are nearly identical:
Business & Prof. Code, §4982. (v)
Unprofessional conduct includes, but is not limited to, the following: Failure to keep records consistent with sound clinical judgment, the standards of the profession, and the nature of the services being rendered.
CAMFT CODE OF ETHICS
§5.3 CLIENT/PATIENT RECORDS: Marriage and family therapists create and maintain client/patient records consistent with sound clinical judgment, standards of the profession, and the nature of the services being rendered.
3. WHAT ARE SOME OF THE POSSIBLE BENEFITS OF WRITING PROGRESS NOTES?
Progress notes may help to reflect a therapist ’s sound clinical judgment in dealing with complex and challenging treatment scenarios.
Progress notes may be used to comment on legal or ethical issues, which arise during the course of treatment, and the therapist ’s response to those issues.
4. DO PROGRESS NOTES PROVIDE A BENEFIT TO THE CLIENT?
Writing a progress note requires a therapist to contemplate what the client ’s treatment consists of, and how it is beneficial to the client.
5. Explain the difference between “progress notes” and “psychotherapy notes” as they are defined by HIPAA.
Michael Griffin, J.D., LCSW, is an attorney at law and a Licensed Clinical Social Worker. Mr. Griffin received his MSW degree from the USC School of Social Work in 1980, and obtained his LCSW in 1982. In 1998, Mr. Griffin was a member of the first graduating class at Chapman University School of Law and obtained his law license in 2002.
Mr. Griffin has a broad background of experience as a mental health professional and has worked as a therapist, clinical case manager, clinical supervisor and child/adolescent outpatient clinic director, and was the Director of Clinical Operations for Western Youth Services in Orange County, California. He also served as a BBS oral examiner for LCSW candidates.
For several years, Mr. Griffin was employed in the department of Psychiatry at Rady Children ’s Hospital in San Diego, CA., where he worked as a child- family therapist, clinical supervisor, and outpatient clinic director, and was the coordinator of school-based mental health programs. Mr. Griffin is a practicing psychotherapist in Orange County, CA., and is an attorney with CAMFT, where he consults with CAMFT ’s members regarding legal and ethical issues.