Risk Management
Risk to you occurs when you are not practicing your profession according to State statutes. Risk would include charting irregularities, breaches of confidentiality, and many other oversights of good therapy proactices, including poor legibility of your notes. GoalMinder's features result in automatic reduction of risk in that they accomplish the following:
- Session notes are always legible because they are typed.
- They automatically contain the session date and time, name of the client scheduled, name of the therapist(s) present, and professional degree of the therapist.
- Also included when the therapist uses drop-down list features of the program are the service provided (the name of the CPT code, like 45-50 minute psychotherapy) and the treatment modality (eg, cognitive behavioral therapy).
- The session note itself can follow a predetermined outline, decided by the clinic, or it can be left to the therapist to organize as s/he sees fit.
- Each note repeats the initial treatment plan, including it automatically so that the therapist can better relate the current day's session to the overall treatment plan.
- When the medication panel or laboratory panel is used, the information identified there automatically appears in the session record for that day.
- Therapists are prompted for notes they have not written. An asterisk appears before a date of service in the treatment area of the program for those notes not yet written.
- A simplified electronic signature insures that once a therapist signs a note, it cannot be changed.
- A separate panel within the treatment area (Note to chart) allows the therapist to document phone calls, collateral interviews, or anything else about the case that did not occur during a session.
In short, the program guides the therapist through correct principles of recordkeeping by just "being there", since that is precisely what the program is constructed to do!