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We are looking for examples or samples of either Behavioral Health Progress notes or Group Therapy notes that use a different format than just large text fields in which the therapists can enter their notes.
We recently had a review of our Behavioral Health notes to get a sense of how they would be evaluated in an audit.
Noted areas of weakness were in our Progress note and our Group Therapy note. Both notes have multi-line edit boxes in which therapist can enter their text:
- Progress note: forms with text fields for ‘Specific Issues Discussed’, ‘Assessment’, ‘Plan’
- Group Therapy note: form with text fields for ‘Discussion Topic’ and ‘Specific Issues’
For our Progress note, the feedback we received was that the paragraph formats were difficult to review to pull out such issues as: specific goals and objectives, patient’s response to treatment, progress achieved. The Group Therapy note had similar feedback about its paragraph format.
If anyone has examples or screenshots of Behavioral Health forms that take a different approach to documenting the visit we would appreciate knowing what your forms and chart notes look like.
Thanks.
Joan Nordberg
Boston Health Care for the Homeless Program
Posted : September 3, 2014 10:02 pm
Joan,
We would also be interested in hearing about ideas on this subject. Depending on the response(s) to this post, perhaps the solution would be to design a form from scratch.
To that end, we would be happy to work with you on the VFE programming to make this so.
Thanks.
Posted : September 3, 2014 11:41 pm
