Best Practices for Documentation
The Golden Thread in the Real World
Learning to incorporate the Golden Thread throughout your practice documentation is important to ensure you can justify continued services with a client should you happen to face an audit or other more thorough peek at your recordkeeping. But doing so in a meaningful and intentional way can be tricky. Follow some of these pointers to help you do so.
Photo by amirali mirhashemian on Unsplash
In a previous post, I discussed the concept of the Golden Thread — a systemic approach to documentation that weaves together all components of the treatment process in a cohesive way. It's essentially the gold standard and this post will break down each of those components individually to help you stay in compliance in documentation throughout your practice — regardless of whether you accept insurance payments.
Check out this infographic for an overview of The Golden Thread.
Know Your Requirements
Before you can start anything, you have to know what you are responsible for documenting.
I often hear of private practice clinicians who don't diagnose or keep scant notes for their clients because they don't take insurance. I mean, more power to them for using shortcuts (smarter, not harder), but there are in fact pieces of documentation that we MUST keep in order to be practicing lawfully and ethically.
Regardless of what treatment setting you are in, there are generally documentation requirements laid out in your state statutes that you need to be aware of. Moreover, there may also be certain ethical requirements (depending on your profession's code of ethics) that further outline what to include in your documentation.
Despite no longer taking insurance, I generally still adhere to DHS and Medicaid/Medicare requirements to ensure I have everything needed in the unlikely event of an audit. Take a look at and be familiar with your state’s statutes to ensure you are including the bare minimum in your recordkeeping:
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Health Service Records: MAR 9505.2175
Minimum Treatment Standards: MAR 9520.0790
Dept. of Human Services: Documentation Standards for Psychotherapy
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Recordkeeping and Retention: WAC 246-809-035
Medicaid: Documentation Requirements
⤳ Diagnostic Assessment (DA) and Diagnosis
The Golden Thread starts with the assessment process, which culminates in a diagnosis from which treatment is informed. We do this through the initial diagnostic interview, collateral information, and the formal written assessment.
The DA is generally a biopsychosocial assessment that inquires about multiple areas of an individual's life. Depending on your states DA requirements (if any), these areas might include their family and social relationships, occupational or school functioning, trauma background, physical and mental health history of the individual and their family, as well as strengths and goals for treatment. Based on this information, a diagnosis is made and the following treatment is informed by the diagnosis.
It is important to note that 50-60 minutes is certainly not enough time to have the full picture and the diagnosis is likely to change as you continue to develop a relationship with your client and more information becomes available. But a thorough diagnostic interview can get you in the ballpark. Of course, if the diagnosis changes, so might the treatment goals.
⤳ Treatment/Service Plan
With an assessment and diagnosis documented, it's time to develop the treatment plan. The treatment plan is not just the goals for therapy, but the direction of treatment itself (i.e. the service plan). All of your progress notes should speak to this service plan.
We start the service plan by identifying treatment goals based on both the diagnosis and the client's desired outcome. These are your long-term, overarching goals that may not be too likely to change unless the diagnosis does. These are generally identified in collaboration with the client in the first few sessions.
⤳ Identify Evidence-Based Interventions
With the long-term treatment goals in mind, we develop short-term objectives, which are smaller steps to reaching the larger goals, and are further broken down into various interventions we plan to use to again address the long-term goals. These interventions include elements like the treatment modality, protocols, or psychoeducational offers you might provide.
A helpful tool for choosing and evaluating treatment interventions:
⤳ Document the Treatment Process
This is where the thread is consistently woven throughout the treatment process. The treatment/service plan should be reflected throughout your progress notes, treatment plan/goal reviews, consultations, etc. -- all of which gets documented in the client chart. This is a concrete way to demonstrate the course of treatment, provide accountability to the work you are doing as a clinician, and speak to progress toward stated goals.
⤳ Discharge
Finally, all of this leads to discharge in some way, shape, or form. Whether treatment goals are completed or the client is lost to contact, a proper discharge summary (stay tuned for a future post) should always be included to document the end of the therapeutic episode. Of course, the client's case can always be reopened, but it means that you essentially need to start the process over again because it is a different episode of treatment.
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While it might seem tedious on the surface, the Golden Thread is meant to provide structure to the treatment process and, if we're being honest, you're probably already doing it! This is just a way of being a bit more aware of the process so that you practice the most intentionally you can to offer the best care to clients possible. You've got this!
Happy writing!
Got any tips or tricks you use to stay consistent with your documentation? Share with us using the comments below!