Clinical Social Work: Documentation

 The 21st Century Cures Act (Cures) is a bipartisan health care innovation law enacted by Congress in 2016 that includes provisions to promote the free flow of health information and interoperability.

 

Electronic health records (EHRs) are becoming popular and many health care providers have adopted them in practice. EHRs are digital versions of paper records which make patient information instantly accessible to authorized users. NASW has received calls and emails from members inquiring whether they will be mandated to use electronic health records in 2014. The purpose of this practice alert is to provide NASW members with a response to this inquiry.

Documenting services for a Medicare beneficiary is an important tool validating that services were performed.

NASW receives frequent telephone calls and e-mail inquiries from members about the differences between psychotherapy notes and progress notes when seeking reimbursement. Confusion centers around the content of these two types of notes, especially when submitting claim information for reimbursement of mental health and behavioral health services.