08. My Progress Note Workflow Using AI: Navigating AI and Ethics when your writing Progress Notes

In this episode of “Run Your Private Practice with AI,” Kym dives into the intricacies of crafting progress notes with the assistance of AI, offering a blend of personal insight and practical advice. Kym emphasizes the importance of maintaining HIPAA compliance, especially when integrating AI tools like ChatGPT into the note-taking process. She outlines a meticulous workflow that balances the efficiency of AI with the necessity for personal oversight, ensuring that progress notes remain comprehensive, compliant, and reflective of each therapy session’s unique content.

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www.progressnotesai.com 

Key points from the episode include:

  • HIPAA Compliance and PHI Awareness: Kym stresses the significance of understanding what constitutes Personal Health Information (PHI) and the critical need to ensure that any AI tool used for note-taking is HIPAA compliant.
  • Efficient Workflow with AI: She shares her own workflow that incorporates concurrent note-taking during telehealth sessions and the subsequent use of AI to refine and finalize progress notes, highlighting tools like Mentalyc and SessionAid for their HIPAA-compliant solutions.
  • Ethical and Accurate Documentation: The episode also touches on the importance of reviewing AI-generated notes to ensure accuracy and avoid the inclusion of irrelevant or fabricated details, underscoring the therapist’s responsibility in the final documentation.

Transcript: 

Hey, everybody. Welcome back to another episode of run your private practice with AI.  Okay. So I get this question all the time. Kym, what does your progress note workflow look like? Uh, there’s a lot to it, but I want to just give you sort of an overview of how I manage it. First of all,  Side note, if you’re ever going to write a progress note, you definitely want to make sure you’re not putting any P.H.I in any system like chat, you P. T. or any of the free chat bots out there that are not HIPAA compliant. There’s a list of 20 things that represent P. H. I. I’m going to read it to you real quick before we even get into this progress network flow.  Okay, so I’m going to read through the list real quick, because I just feel super responsible for making sure that everybody knows what is.

So it stands for personal health information. It’s a client’s name, address dates,. Birth date, admission date, all of that is PHI, their phone number, their fax number, their email address, their social security number, their medical record number, their health plan, beneficiary number, account number, certificate or license number, vehicle identifiers. 

Uh, device identifiers, serial numbers, websites, web URLs, internet protocol, addresses like their IP address, biometric IDs, such as fingerprints or voice print, and full face photographs or any other photos or identifying characteristics that you might take pictures of. I don’t know when we would ever do this, but.

 That’s the list of P. H. I. So I just want you guys to be aware of that before we talk about this. So I do talk a lot on this podcast about using chat. That’s my go to. That’s my favorite one to use the paid version because there’s so many cool features and it’s getting better and better and every day.

If you’re going to write progress notes, be super careful. There are. HIPAA compliant ones out there that you can use. Mentalyc, I just did an episode on my other podcast with the founder of Mentalyc, SessionAid is one, FreedAI, Autonodes, all of those are HIPAA compliant platforms. So if you don’t feel comfortable with this workflow, you could still do it with one of those HIPAA compliant platforms, so. 

Here’s what I do. I have a telehealth session with my client. I take notes concurrently in session because if I don’t, I will never write my notes. So I discovered this concurrent trick a long time ago, and I’ve used it ever since. Really? I’ve been doing telehealth. I never did it in person because I just always felt kind of rude, like, taking notes while I was talking to the client.

But with concurrent note taking, what I do is I am in my EHR. I have the window open where I can see my client. Okay. Bye. And then I open a whole new browser right underneath that window. I open up, you know, simple practice, or if you’re using AI, you could type directly into the AI platform. And I take notes.

I don’t take names. I don’t like specific details. I say, Oh, okay, Lexapro increased to 10 milligrams. Okay. Anxiety, uh, around my spouse yelling last night, reminded me of childhood trauma.  Really nonspecific stuff like that stuff that you could never apply to somebody unless you knew them and you knew their name and information, their PHI.

So  I take general notes like that and then when the session’s over, I literally copy my notes and I put it into  chat GPT, which is, you know, it’s a bot, but you have to train it. So you have to train it to write like you want it to write. You have to train it to produce progress notes like you want it to produce.

I’ve done that in chat. I even created a free GPT called Progress Notes AI. I’ll put the link down here that you can go try to be want to. Of course, no P. H. I go in there, but it’s a tool that I’ve already trained basically to be able to write progress notes for you. It already knows that your clinician, it already knows what type of notes you want to write.

It already knows that you want to meet medical necessity, all of that stuff. I’ll put the link and you can only use it if you have the paid version of chat right now. I think that’s gonna change down the road, but. You know, it’s a tool you can use, so I’ll link it down below. So anyway, I take what I’ve written and I pop this little blurb over into chat GPT, where I’ve already trained it  and I literally hit enter.

And because I’ve trained it so well, now it knows that I’m a therapist. It knows that I really specialize in PTSD, EMDR,  outside of the box modalities like mindfulness, you know, things that, um, or maybe are a little non-traditional, non evidence based. So it knows all that stuff about me.  And it knows that  my preferred format for writing a note is a soap note.

And I do that because most of the insurance companies do say that writing in a soap note format meets all their criteria for medical necessity. Of course, there’s other things. And I have that in a template in my EHR that I use that I’ve created over the years. I’ve tweaked it. And those are basically check boxes.

But for the content of the session, this is how I do it. So, I hit enter. I have it. Create a soap note.  I then, uh, take the soap note. I copy it from what, what the AI just gave to me. I take it over to my EHR. I pulled up the session for today. I hit the populace from last session. And the 1 I use happens to just put the last note in there for you, which is super helpful because it’s already got all my checkboxes.

It’s already got everything checked from the last session. So I take what I created in a I. Okay. I drop it over into the narrative part of my note that I put in my template, drop it down there. I quickly go over the check boxes, making sure nothing’s changed. If it has, I’ll just change a couple of things, um, like around sleep or, you know, um, medical appointments or medication, that sort of thing.

I’ll change those boxes, mental status, if anything’s changed that.  And then I just read over what AI created. You always want to read over it specifically because.  Hey, I do this funny thing where it learns you and kind of, um, understands what type of clients you work with and that sort of thing. If there’s information missing in the data that you put in, it’ll make up a story sometimes.

So it’ll kind of be like saying, oh, yeah. And also they went to the store and got into a fight with them. The manager at the store, likes just really random things. Sometimes it’ll interject it into the notes that it creates. So  always double check what it writes. I know we’re busy. So sometimes, you know, you might really be tempted just to copy this thing that output for you and just pop it into the note, hit, save, lock the note and be done with it, but you can’t do that.

You have to double check this. You have to make sure it’s accurate. So then you just go over.  Uh, put in the H. R. double check and make sure everything’s alright. Do your check boxes and hit save lock and your notes done. So that literally is my workflow. It’s super easy. If you’re not using chat, if you want to use 1 of the other ones. 

There’s a lot of these, uh, programs now that basically they record your session. They, you know, ask the client’s permission to record. You both say, yes, it records the session and it literally just takes your transcript and turns it into a progress note.  And, you know, these programs are becoming a lot more advanced.

They could turn it to a progress note. It can generate a treatment plan from what you just talked about,  uh, going back to my progress note process and chat. Even once it writes the note, you can say, all right, now I want you to turn this into a treatment plan. I want to have two goals, objectives and some very specific goals.

Measurable interventions that I could put into this treatment plan that go with this note that you just wrote and then it can take that advice and it writes these amazingly well crafted. Notes for you and treatment plans for you that all are connected  because we know with clinical documentation, we have to follow that golden thread always.

We need to make sure that the assessment matches the diagnosis. The diagnosis matches what you’re writing about in your progress notes. Your progress notes need to meet your treatment plan and it all needs to be connected  from start to finish and start to discharge.

You need to be showing how you came to this conclusion, how you’re treating this. Diagnosis and how the client is progressing. So you want to be able to use all of that.  So that’s my progress network flow. I hope that helps. It makes sense. If you have questions, let me know. I want to give you a couple of prompts you can use to just put in there.

If you don’t want to use chat GPT, if you don’t want to, if you don’t want to use one of the paid versions, a safe way you can put some stuff in to not violate HIPAA, but also get some really cool notes immediately. So I want to read this prompt to you and just say that in the clinical AI club that I created for therapists  to help run their private practice, the AI. 

Every month I do a topic and one month we did progress notes specifically. So there’s about, I think there’s about 40 prompts in there around writing progress notes, but I want to give you just a general one to get you started. If you want to try it, it says,  I am a licensed clinical social worker. I see clients usually with a PTSD diagnosis or chemical dependency diagnosis. I tend to use mindfulness strategies, cognitive behavioral type strategies, and other interventions that might be considered out of the box or less usual than other clinicians might use. I want all my notes written in SOAP note format and I want all my notes to reflect medical necessity because I’m an insurance based provider. 

I want to make sure if an insurance company reviewed these notes, they would meet the criteria for medical necessity and an audit. Okay. So that is a prompt you can use. You can obviously curtail it to your specialty, your licensure, that sort of thing. The type of  note format that you want to use, it’d be like DAP or BIRP or different kinds of notes.

You can just tell it what kind of note you want to write so that’s a prompt that you can use to get started. So I would just suggest, you know, if you want to try it out, go over to chat. It’s a chat. openai. com you can go there, you can sign up for a free account.

Just don’t put any PHI in anything that even remotely identify who your client is. You don’t do that. It should be fine. I know everybody’s worried about that. If you’re not comfortable with using chat GPT, you can still do it concurrently. note taking during your sessions and then use one of these paid HIPAA compliant platforms or even one that just records the whole session.

So you can skip having to type anything. You can just be totally present with your client. You know, it’s recording and that they’re going to make a progress note for you after the session’s over. So it’s like magic  either way is super efficient. Somebody just asked in one of the Facebook groups, um, you know, how efficient is this for you?

And once you get the system down, it saves  so much time. You literally don’t have to think of what to say. I don’t know about anybody else, but I hate soap notes. I hate trying to think like, what is subjective versus objective? What is my assessment versus my plan? You know, all of that, I, I always hated trying to figure that stuff out, but you don’t have to now because AI does that part for you.

It makes it super easy. You just have to remember to go back and read over it and make sure  that it’s not interjecting thoughts or ideas or clinical judgment around what’s happening with the client. We still have to maintain that responsibility. We have to make sure that we’re, you know, being careful about what we’re putting in our client record.

We can’t just copy and paste and forget about it. Cause I know it’s very tempting to do that, especially when the whole notes are already written for you. Um, so anyway, I hope that helps let me know what you think. Let me know if you have questions, come join us in the clinical AI club. If you want to learn more.

It’s www.clinicalaiclub.com. Okay. Have a great day. Bye bye.