The Golden Thread: Your Key to Complete Documentation

By TherapyNotes, LLC on November 15, 2017

(...and maybe even a good night's sleep.)

Documentation is one of the most important components of rendering services – if it isn't documented, it didn't happen. Writing mental health progress notes can be both simple and complicated. It's easy to record what happened in a session, but it may be significantly more difficult to do so in a fully compliant way.

The APA Record Keeping Guidelines discuss the myriad of complexities involved with documentation, from legal jurisdiction and ethical requirements to professional context and client wishes. Mental health progress notes can be further complicated by varying requirements from third-party payers, and this may keep clinicians and practice owners up at night. The fear of audits by insurance companies (and any subsequent takebacks) is real; audits may easily blacklist or even bankrupt a practice for an honest mistake.

Having a complete psychotherapy progress note template can be one of the most important resources in combating failed insurance audits, and having a series of note templates that reflect the full scope of services provided is an even better defense. Using a series of note templates including intake assessments, treatment plans, progress notes, and a discharge summary can help you create the Golden Thread, an important concept for creating rich documentation.


What is the Golden Thread?

The Golden Thread is the consistent presentation of relevant clinical information throughout all documentation for a client. The Golden Thread begins with an intake assessment that clearly identifies an appropriate clinical problem and corresponding diagnosis. Next, the treatment plan should reflect a clear series of goals for helping the client through the identified problem. Each goal should have specific interventions prescribed that reflect best practices and evidenced-based treatments to help guide the client along the path to recovery. Finally, the Golden Thread includes progress notes that demonstrate that the services you deliver match what was prescribed in the treatment plan. Each note should lead into the next, creating a comprehensive story of the client's progress through treatment.

The Golden Thread is not only important for compliance and reimbursement, but it can also be an important tool for delivering quality care.

TherapyNotes - The Golden Thread and Rich Documentation


Does TherapyNotes have note templates that I can use?

We designed our electronic documentation system with careful attention and research to ensure that our note templates reflect the different services that mental health professionals provide. Information automatically pulls forward from each note to the next, helping to ensure that the Golden Thread runs through all of your documentation, and custom intervention lists per clinician allow you to have your own unique intervention methods readily available on each progress note.

Our note templates ensure you never miss a critical component of information while allowing for clinically rich documentation. You can rest easy knowing that your documentation is well done.

Ensure the Golden Thread runs through all of your documentation.

Talk with a member of our Success team and learn how TherapyNotes can help.

Schedule a Consultation

* The content of this post is intended to serve as general advice and information. It is not to be taken as legal advice and may not account for all rules and regulations in every jurisdiction. For legal advice, please contact an attorney.


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