How to write progress notes for online therapy sessions

The current global pandemic has significantly impacted people’s mental health. A recent survey by the American Psychiatric Association found that 36 percent of respondents thought that COVID-19 was having a “serious impact on their mental health.” With such a sharp rise in mental health concerns, the need for skilled therapists is increasing.

Unfortunately, therapists are facing their own challenges because of the pandemic. Many have made a sudden transition to online visits, which can be a difficult adjustment for both them and their patients. Now therapists need to figure out how to make these online visits as effective for patients as in-person sessions.

What can help you improve your online visits? In this article, we’ll examine why progress notes are an essential tool for virtual visits and how you can use technology to take better notes.

Progress notes help you provide better treatment

It can be hard to keep track of what’s happening in an online visit. With all the background noise, distractions, and technical difficulties, remembering important points can feel impossible. Progress notes help you collect all your thoughts and relevant information in one place to better serve your needs and the needs of your healthcare organization. Progress notes can help you

  • Collect vital patient information. Recording important patient data, such as whether a treatment plan is working, provides a timeline of your patient’s mental health. Having a record of this information also helps you make better diagnostic and treatment decisions.
  • Record the care you provide. Therapists provide essential care. However, that care isn’t always as evident as in other medical fields. By creating a record of your clinical judgment, you’ll have documentation that shows what type of care you provided in case of legal issues or billing concerns.
  • Bill accurately. It can be difficult to figure out how to get insurance companies to reimburse you for online visits. Keeping a record of information that’s relevant for billing, such as billing codes and session dates, can help you ensure that you get accurate compensation.

Progress notes allow therapists to get the most accurate data possible for their records. But how can you be sure you’re saving the right information? Understanding the purpose of your notes can provide you with guidelines that help you prioritize the most important information.

The best notes focus on essential information

A therapist checks over previous progress notes for a patient.

Progress notes include many different components, from the patient’s medical history to how you conduct the visit. With all of this data to keep track of, it can be difficult to stay organized. A basic checklist can improve your progress notes and ensure you don’t miss anything essential. Here are some key elements to include in every note:

  • The patient’s current mental state
  • The patient’s medical history
  • The patient’s current medication list
  • The patient’s treatment plan, including whether the current treatment is proving effective
  • Any changes you make to their treatment plan at the time of the visit
  • The mode used for the appointment (online or in person)
  • The billing code
  • The duration of the appointment
  • Your clinical judgment of the patient’s situation
  • Safety issues, such as whether the patient is a danger to others
  • Referrals (if needed)
  • Any concerns about abuse in the patient’s life

By making your notes more comprehensive and focused, you’ll get a better picture of your patients’ health over time and prevent legal problems. While a progress note checklist by itself is useful, you can make it even more effective by upgrading your checklist to an online template. Using an online template can help you automate the way you collect health information.

Using an online template speeds up your note-taking process

Online templates provide a quick, easy way to take notes during a virtual visit. Templates include all the relevant fields for progress notes, allowing you to organize your information easily. You can also customize online templates for specific medical conditions or mental health concerns.

When you’re choosing which type of online template to use, make sure to look for a business that offers HIPAA-compliant forms. For instance, JotForm’s online templates and forms are HIPAA compliant (if you’re on a Silver or Gold plan), so you don’t have to worry about sensitive information being lost or stolen from your notes.

By using a template for your progress notes, you can easily organize all the information you need to collect. Improving your note-taking skills enhances your online visits and your patient care.

Let me go over my notes from last time

Many people are experiencing mental health challenges due to the pandemic. One way you can help patients while you adjust to online visits is to improve the way you take progress notes. By leveraging online templates, you’ll speed up the note-taking process and ensure that you include all the relevant information.

AUTHOR
Firm believer in personal data privacy in the age of information. Close follower of the new regulations concerning patient confidentiality & HIPAA. You can reach George through his contact form.

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