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Documentation Of Behavioral Health Services

16354490_300Most integrated clinics maintain behavioral health consultation responses and follow-up notes in the client’s general medical chart. However, given that medical records are fairly open and accessible products, the counselors must balance concerns about documenting sensitive issues in the record with the need for other health care providers to know certain information. Sometimes, other forms of communication may be the best way to relay information.

Initial Visit
Initial documentation generally contains the following information:

  • Who requested behavioral health involvement and the referral questions, if applicable;
  • Pertinent assessment findings (e.g., symptoms of mental disorder, life stresses, relevant psychosocial issues, etc);
  • Clinical impressions and functional symptoms;
  • Recommended interventions and person(s) responsible for executing them (e.g., counselor, primary care provider, client, etc.) and suggested time lines;
  • Follow-up plan recommendations.

Follow-up Consultation Notes
Generally, documentation of consultation visits includes:

  • An assessment of the patient’s adherence and response to interventions initiated previously by the counselor and/or primary care provider;
  • Recommendations regarding continuing or modifying intervention strategies, including the person(s) responsible for implementing them;
  • A brief statement regarding the follow-up plan if any changes are needed;
  • A record of kept and missed appointments. It’s a good idea to apprise primary care providers of missed appointments for appropriate follow-up.