susanlitton

About Susan Litton

Susan C. Litton, Ph.D. holds degrees in both psychology and IT. In addition to being the developer of the PSYBooks EHR & Portal, she's been a practicing clinical psychologist in Decatur, GA, since 1985.

When You Have to Produce a Medical Record

Before I started using practice management systems, being required to produce a client’s medical record was a bit scary for two reasons:

  1. First, I typically only received those requests when something important was going on, i.e., a legal proceeding of some sort, a disability or worker’s comp situation, or maybe something having to do with insurance. They were the kinds of things where I felt that a lot might be at stake for my client (and/or for me) so I wanted to make sure I “did it right”.
  2. Second, although I had my own system for organizing client files, the reality is that my records were scattered everywhere. I kept files on current clients in one filing cabinet – unless a certain file got too big, in which case I moved older portions of it to another filing cabinet, unless there was also large artwork in the file, in which case it had to go in the lateral filing cabinet. When a client terminated, files got moved to a storage area in my basement at home. If the client later returned and their file had been especially large, part of it would be brought back to my office, but older parts remained in my basement at home. Then, of course, some documents were on my computer – a smattering of various Word docs and Excel sheets I had pieced together for special notes I had written on clients, letters I had written on their behalf, and various attempts at coming up with THE perfect method for determining how much a client owed me when insurance was involved. I had also tried efiling for awhile at various insurance company’s websites, so some of my records were on various sites on the Internet, too. Somehow, when I was asked to produce a medical record, even though I knew I had everything I needed, finding it all and pulling it all together into some type of meaningful report was a daunting task.

Your Personal Psychotherapy Notes (Hint: These Are NOT Part of the Client’s Medical Record)

PSYBooks does not store Psychotherapy Notes in the same way it stores notes that are part of the client’s medical record. Psychotherapy notes are meant to be places for you to record your personal thoughts or ideas about a client so they are stored separately. There is one note type in PSYBooks that is always in the Psychotherapy note category and four others that you can designate as Psychotherapy or Medical Record notes:

Medical Record Notes

Almost all forms in PSYBooks have a section where you can enter notes. Most of these notes automatically become part of the client’s medical record, although a few allow you to designate the note as a personal psychotherapy note (i.e., not part of the medical record). PSYBooks breaks medical record notes into two categories: clinical medical record notes and admin medical record notes. This is done to allow you to give permission for a User to see one type of note but not others. For example, you might want your front office staff to be able to see your admin medical record notes (e.g., a note you might have attached to a client payment), but not your clinical medical record notes or your personal psychotherapy notes.

New Features

We love coming up with new features for PSYBooks. It’s probably the most fun thing we do. When we release a new feature, your account will automatically get the update. If it’s a substantial release, we’ll email you and/or notify you next time you sign in to give you a brief description of the new feature and what it does.

Automatic Updates

PSYBooks is updated frequently. Most updates are small such as a minor bug or misspelled word which we fix and then refresh all instances of the application to reflect the change. Those kinds of updates are considered routine maintenance and most likely, unless you happened to notice the problem to begin with, you won’t even realize anything changed. This is one of the beauties of the Web. Unlike print material or software that you download, we can make updates and improvements as often as needed and deliver them to you right away.