Communication & Documentation

Communicating with physicians as team members in primary care (very different from as a referral destination in specialty care) requires a keen sense on the part of the behavioral health clinician of what is important to your colleague. Communication is written with the assumption that the physician is still the person leading the team to care for the patient. (Competing with the physician for “whose patient the person is” will cost the BHC influence on the team and in the practice as an organization.) The communication should be targeted to what the physician needs to know in order to feel she has a good grasp on the big picture from a medical perspective. Examples of successful communications are brief, businesslike and supportive of overall team functioning.

It is often a real challenge for psychologists and other mental health professionals to move from writing psychotherapy notes (must be treated with some boundary to access) to writing progress notes which are part of the general medical record. When I first started making this shift as a primary care clinician, writing progress notes only with no second longer note behind the “glass," the Compliance Department of the hospital, on behalf of the Psychiatry Dept, came to see me. They said I was vulnerable to having to refund billing because in my notes I wasn’t covering all that needed to be covered to justify billing. The compliance officer was a very nice and bright person who completely understood my claim that dual records were not efficient and that long psychotherapy notes, even if I could make them available, were non-communicative to my physician colleagues. He knew all the rules and made the point that the payer has the right to know what the clinician did, but not the right to know the content, eg., to know that I did behavioral activation but not that the patient had agreed to go visit his daughter twice a week. Ultimately we came up with a form full of checkboxes that covered the things a payer needs while leaving a short place for text that is communicative with the PCP. In addition, I always read the text part of the note to patients when they came back, so that my documentation was a clinical intervention, a vehicle for clinical transparency, a team communication, a documentation for billing, a record adequate should a colleague need to interact with the patient in my absence, and a record of the things I needed to remember to continue our treatment at the next visit. I had to fill these out in Word and paste them into the EMR but that didn’t add any time. I have attached the note template.

Alexander Blount, EdD

Professor of Clinical Psychology

Director of the Major Area of Study in

Behavioral Health Integration and Population Health

Antioch University New England

Professor of Family Medicine and Psychiatry

Director Emeritus, Center for Integrated Primary Care

University of Massachusetts Medical School