A Closer Look at Documentation Practices

In this video taken at the 2024 Psych Congress NP Institute, Julie Carbray, PhD, PMHNP-BC, APRN, Co-Chair, Psych Congress NP Institute, and Desiree Matthews, PMHNP-BC, Steering Committee, Psych Congress NP Institute, discuss together the details of documentation best practices in clinical practice. Together, Julie and Desiree revisit the basics of documentation: why clinicians do it and how to best approach it so that it is more helpful than hindering when reviewing notes. From guiding clinical care to providing justification for billing codes and prescribing choices, every clinician can benefit from reviewing their current documentation practices to ensure they support improved patient outcomes.

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Julie Carbray, PhD, PMHNP-BC, APRN: Hi, I am Julie Carbray. I'm a clinical professor of psychiatry and nursing at the University of Illinois--Chicago, department of psychiatry and College of Nursing. Desiree?

Desiree Matthews, PMHNP-BC: Thank you, Julie. My name is Desiree Matthews. I'm a board certified psychiatric nurse practitioner. I'm owner and clinical director at Different MHP in Charlotte, North Carolina.

Psych Congress NP Institute: What are the top 3 reasons why advanced practice providers document?

Julie: Desiree, I would say one of the largest reasons we need to document is to guide our care and to be able to connect why we're doing what we're doing, not just because of compliance issues or billing issues, but also to help guide our treatment and remind us from session to session what we're doing to best improve the care for our patients. What about you? What do you think would be some of those top 3 reasons?

Desiree: Yeah, certainly as you mentioned, that communication piece. I think it's so important to keep that communication in our notes concise and what we put in there to be of, again, diagnostic and prognostic value. I've seen some pitfalls where, again, you're sorting through these emergency room and inpatient notes, and they're repeating themselves over and over. I think sometimes our EHRs, by the time we print out these notes and another organization is looking through them, it is 40, 50 pages long of information that's repeated. So for me, brevity is key, but again, we also want to make sure that we're communicating our points and for me, the treatment plan and making sure that is clear what medication I'm using, why, and exactly the plan for next time.

Julie: Yeah, that's what I always share with my students is another provider should be able to take a look at your note, understand what you're doing and why, have some patient feedback about why you're doing that. Also, of course, the notes should substantiate your billing codes and meet our compliance regulations, but be brief as possible.

Desiree: Exactly. I think as well, when we think about treatment access, so in my case, I have a lot of patients that may need medications that aren't generic, that are branded. So for me, my notes also have to substantiate what I'm asking for from the payer. So a lot of times I make sure to use rating scales like the PHQ-9 especially to demonstrate not only severity but improvement. Things like VMAT2 inhibitors, right? The AIMS scale again to show the severity in terms of the AIMS as well, hopefully improvement over time. What about you? Any rating scales?

Julie: Yeah, I'm thinking too, because I work a lot with children, we'll incorporate either a mania rating scale or an ADHD rating scale. Similarly, sometimes I need to communicate around prior authorizations, and I want to assure that there's excellent documentation about what agents have been tried, where are the symptoms, severity indexes on different scales, as well as of course, the tolerability, because that then can present an excellent case of why we’re moving forward with an alternative treatment.

Desiree: Certainly. Then of course, last but not least, that functional impact that our patients are having, whether they're pediatric with ADHD, or perhaps patients with tardive dyskinesia and their movements.

Julie: So it's really that delicate balance of being brief, but comprehensive and including as many sources of information as we can so that any clinician might take a look at the note and be able to glean all of that and walk away understanding what we're doing, why, and for how long.

Desiree: Completely agree.

So I hope this was helpful for your practice in terms of learning how to make sure that we document in a way that helps provide excellent patient care communication to other healthcare professionals, as well as to help support your billing and coding to ensure that you are getting reimbursed for the work that you're doing with your patients.

Julie: Yeah. Thank you so much for joining us. Look forward to hearing more tips and tricks from our experts in this area, really trying to help us to be able to not only provide that excellent care, but attend to billing coding that really makes it necessary for us to continue to be there for our patients in meaningful ways.

Julie Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, holds her PhD (93) and Master of Science (88) degrees from Rush University, Chicago and her Bachelor of Science (87) degree from Purdue University in West Lafayette, Indiana. A clinical professor of psychiatry and nursing at the University of Illinois Chicago and the director of the Pediatric Mood Disorder Clinic, she has been practicing as a Psychiatric Nurse Practitioner for over 35 years.

Desiree Matthews, PMHNP-BC, is a board certified psychiatric nurse practitioner with expertise in treating patients living with severe mental illness. Beyond clinical practice, Desiree has provided leadership in advocating for optimal outcomes of patients and elevating health care provider education. Desiree is the founder and owner of Different MHP, a telepsychiatry practice founded with the mission of providing affordable, accessible precision focused, integrative psychiatry to patients through a rich and comprehensive mentorship of the health care providers within the company.

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