How Headway defines clinical quality
Headway is deeply committed to clinical excellence. We believe in supporting our providers in delivering high quality, evidence-based treatment that is matched to the individual client's needs.
The Headway Clinical Team partners with our providers in identifying and encouraging quality improvements for Headway’s care delivery, always with the overall goal of improving the quality of healthcare patients receive through Headway.
Per our Documentation Policy, Headway is committed to ensuring that documentation, coding, and billing practices are in compliance with all federal and state regulations, payer requirements, and clinical best practices.
How Headway evaluates clinical quality
The Clinical Team reviews documentation with a focus on patient safety, evidence based clinical care, and billing requirements. At Headway we are committed to making sure communication around documentation and clinical quality are clear so that providers can take action to make improvements to reduce risk to patients and their practice.
In cases where deficits are found, you may receive an email or a meeting request from a member of the clinical team to notify you of the documentation concern, provide support on improving your documentation, and connect you with resources for ongoing education. We believe in providing support to clinicians to help improve the safety, efficiency, and quality of their documentation.
Resources for quality documentation
The Headway Clinical Team has developed a list of essential documentation elements that must be included in each new patient intake note to help meet minimum quality documentation standards. Incorporating these key elements in your documentation can help ensure providers clearly document the high quality healthcare they deliver. These documentation standards help communicate patient’s behavioral health conditions throughout their journey and help our providers protect their own practice liability.
Below, find each key component and an explanation (click to expand):
This is the documented reason for seeking treatment, usually 1-2 sentences in the patient's own words. Typically a quote or brief description of the current reason the client is at the appointment.
i.e. “I haven't been able to sleep well for months and I am hoping you can help."
This section should include:
- Each of the symptoms currently present
- Time of onset of symptoms - when did each symptom or symptom cluster start
- Duration of symptoms - how long has it been going on
- Frequency of symptoms - when are symptoms experienced (i.e. only at school)
- Quality of symptoms - how the patient describes their symptoms
- Modifying factors - what makes symptoms better or worse
- Severity and Functional Impairment - to meet DSM criteria this must be addressed
- Context - psychosocial or structural factors negative or positively impacting the patient’s symptoms
- Prior episodes of these symptoms including prior diagnoses
This section should provide the full symptom criteria and time course to support the diagnosis provided in the assessment and diagnosis section of the note.
The Psychiatric ROS provides information about pertinent positive or negative psychiatric symptoms. This is where you document that you asked the patient about key symptoms to rule out/in differential diagnoses such as symptoms of mania, depression, anxiety, obsessive thoughts, trauma responses, or psychosis.
This section provides information for the differential diagnosis discussion. There may be some overlap with the HPI or psychiatric history.
Documentation of a client's use of or lack of use of substances must be present.
- Alcohol
- Cannabis
- Amphetamine
- Cocaine
- Opiates
- Benzodiazepines
- Nicotine
- Other
Documentation should include age of first use, general timeline, and the presence of tolerance, withdrawal, or other substance dependence behaviors.
Documentation of the patient's psychiatric treatment history including diagnosis, treatment type, providers, duration, hospitalizations must be included.
This information may include the patient’s history of:
- Prior diagnoses and symptom clusters (i.e. ADHD dx at age 8 by psychiatrist due to impulsivity and difficulty sustaining attention in 2nd grade classroom and at home)
- Psychotherapy treatments
- Psychiatric medication treatment (dose, duration, time of use, impact, side effects)
- Day programs or partial hospitalization programs
- Prior suicide attempt, self-harm, harm to others or risk behavior
- DDS or DMH involvement
A statement regarding the past history of trauma including time period (i.e. early childhood, adolescence, early adulthood).
Identification of the patient’s social history and patient’s social support.
A summary of the patient’s medical history. If there is no significant medical history then documentation must indicate that the provider asked about prior health issues such as hospitalizations, surgeries, allergies, and medical conditions.
Documentation of a list of current medications the client is taking including name, dose, duration, reason for taking.
Documentation of other outside providers and coordination if needed.
A mental status exam is your assessment of the patient and must be documented in every note.
Key content areas include:
- General appearance
- Orientation x1-4
- Speech including rate, rhythm, tone
- Mood, (i.e. dysthymic, depressed, euthymic, anxious, manic, hypomanic)
- Thought process (i.e. linear, loose associations, tangential, disorganized),
- Thought content (AVH, SI, HI) - if + safety plan should be documented
- Judgment
- Insight
- Cognition
A risk assessment of homicidality and suicidality must be documented.
- Current suicidal or homicidal ideation should always include intent, plan, and means.
- A safety plan should be documented for anyone with SI, self-harm, or HI
- Documentation of self harm including details surrounding events.
- Documentation of violence towards others should include details surrounding events.
- Past history of risk to self or others and current protective and risk factors should be documented.
If SI, HI, or potential harm is present, a safety plan must be present. Items to consider including:
- Warning signs
- Coping strategies
- Social settings and supports
- Professionals or agencies the client can contact in crisis
- Ways to make the environment safer (i.e. storage of medication, removal of weapons
This is where you formulate your assessment and diagnosis by synthesizing the subjective and objective data. Documentation of a rationale for your diagnosis that includes how the patient reported data, history, and your examination data meet the DSM-V criteria for the diagnosis you are documenting is required. It is important to include severity and any functional impairment.
The patient reported, subjective data, should be present in greater detail in the HPI and past psychiatric history.
An evidence based treatment plan that is medically appropriate for the client's condition (ie. antidepressant medication for a diagnosis of MDD).Treatment may include multiple modalities such as individual therapy, medication, or support groups.
If off-label treatment is utilized it must be justified in documentation with rationale and evidence base.
The prescription must include medication name, dose, frequency. Rationale for polypharmacy or multiple medication changes should be documented.
If the prescription is a controlled substance or the patient is on a controlled substance your state PMP should be checked and results documented.
For any prescribed medication there must be either verbal or written and signed informed consent that includes specific side effects, risks, benefits, and alternatives to the recommended treatment.
If the patient is a reproductive-aged female and is on a teratogenic medication the client should be screened for pregnancy and IC about risk specific to pregnancy should be documented. IC should take into consideration risk/benefit related to the patient’s specific medical conditions and risks.
Documentation of appropriate labs in accordance with medication management guidelines or documentation of request/review of outside labs (i.e. PCP).
- Antidepressant panel (CBC, Chem panel, TSH, T4, UA, pregnancy) (*recommended but not required)
- Antipsychotic panel (CBC, Chem panel, TSH, T4, UA, pregnancy, fast lipid and glucose, wt check qmo) (required)
- Mood stabilizer panel (CBC, Chem panel, TSH, T4, UA, pregnancy, Li/VPA/CBZ level, wt check qmo) (required)
Headway Academy educational offerings
We understand that for many clinicians documentation is something that takes a great deal of time and effort. At Headway, we're continuing to make strides in making this process easier for you so that you can improve your practice and focus more of your time on patients.
The Clinical Team offers short, easy-to-digest courses to assist in quality care delivery. We put together a learning pathway that includes the following courses (click the links below to be redirected to each individual course):
| Course | Description |
|---|---|
| Golden Thread [5 minutes] |
This course dives into the Golden Thread concept, a crucial element that ensures continuous and consistent documentation across all client interactions. Through a short video lesson, participants will explore how to construct a client chart that stands up to insurance audits and enhances the quality of care. The course covers the creation and integration of intake assessments, treatment plans, progress notes, and discharge summaries. By the end of this course, therapists and prescribing level clinicians will not only be adept at weaving the Golden Thread through their documentation, but also at elevating their practice's standards and safeguarding against compliance risks. |
| Clinical Consultation and Intake for Mental Health Therapists [10 minutes] |
Unlock the fundamentals of conducting effective mental health intake sessions with our comprehensive course designed specifically for non-prescribing mental health professionals. This course will guide you through the critical steps of initial client consultations, helping you to establish a strong therapeutic alliance and gather essential information for accurate diagnosis and effective treatment planning. |
| Differential Diagnosis [10 minutes] |
This course enhances your diagnostic skills in differential diagnosis. You will learn the foundational principles of differential diagnosis, focusing on symptom history, frequency, and functional impairment. |
| Risk Assessment and Safety Planning [10 minutes] |
This brief course is designed for mental health professionals who aim to refresh their expertise in identifying, assessing, and managing risks associated with mental health conditions. With a focus on promoting patient safety and well-being, the course equips participants with the necessary tools for effective risk management in their practice. |
| Medical Necessity [10 minutes] |
Navigating the complexities of medical necessity can be challenging for healthcare providers, but it is crucial for ensuring insurance coverage and delivering appropriate patient care. This comprehensive 10-minute course provides a clear and concise overview of what constitutes medical necessity, based on accepted medical standards and criteria. |
| Write compliant intake notes, treatment plans, and progress notes [15 mins] | Understand insurers' expectations and industry standards so you can confidently document your sessions. |
Continuing education for clinical quality
Headway offers Continuing Education Units (CEUs) through our partners Violet and PESI. You can learn more about our offerings here: Using Violet and PESI for continuing education with Headway.
Live support Headway offers on clinical quality
We understand that you may have questions about Clinical Quality, and we have dedicated Clinical Leads to support you.
You can sign up for Clinical Quality office hours here: