This statement regarding the American Psychoanalytic Association practice guideline entitled Charting Psychoanalysis (Gray and Cummings, 1995) clarifies the position and reasons for our belief that the standard of care does not require a progress note to the effect that certain reportable events did not occur in order to establish that such events did not occur or a note to the effect that modalities of care which fall outside the scope of psychoanalysis and modified psychoanalytic treatment were not prescribed or performed by the treating psychoanalyst in order to establish that such modalities of care were not prescribed or provided. The need to clarify these points has arisen from the following circumstances.
Within various health care professions, there has been a recent expansion of the usual and customary practice of maintaining progress notes to document various issues which pertain to reporting laws and insurance policy. In response to medical-legal pressures and in an effort to comply with various laws and regulations, many health professionals now record progress notes that clarify not only what took place in the treatment but also the fact that certain conditions and events were not present or did not take place. The latter procedure, commonly referred to as negative charting, serves to maintain documentation that the treatment plan continues to be valid and appropriate because changes or conditions which definitively call the treatment plan into question do not exist.
Until recently, this practice of negative charting was substantially confined to issues and matters related to the patient's chief complaint. Particularly during periods of evaluation, a professional might record the absence of events which relate to confirming or eliminating a particular differential diagnosis. In recent times, however, the practice of negative charting has been expanded to serve new purposes. In some localities, laws dictate that progress notes contain information to confirm that imminent concerns regarding life threatening behavior (suicide or homicide) are not present, that definitive indications for the prescription of medication have not emerged, and that evidence to raise a suspicion of the occurrence of events which are legally mandated to be reported to outside persons and/or authorities (e.g. child abuse, sexual molestation, or Tarasoff conditions regarding immanent danger to others) are not present. The practice of ongoing repetitive negative charting is frequently performed over the course of treatment in an attempt to document that a clinician obtained all relevant information, considered all relevant factors and all available treatment options, and thereby having done so was not negligent. These forms of accountability documentation can serve as a means to defend against lawsuits and as a means to defend against threats of contemporaneous or retroactive denial of reimbursement by third parties who may be prone to question the appropriateness of a treatment plan if certain conditions are not verified to have been ruled in or out in an ongoing manner.
The guideline on Charting Psychoanalysis which was approved by the Executive Council of the American Psychoanalytic Association in December 1994 refers to psychoanalysis as a unitary procedure and recommends “that psychoanalysts refrain from documenting psychoanalytic treatment session by session.” It explains that “documenting the content of a psychoanalysis seriously alters that treatment process and conflicts with fundamental clinical psychoanalytic skills.” The guideline implies but does not specifically state and clarify its position on the problem raised for psychoanalysts by the frequently performed practice of negative charting which may be a part of the general guidelines recommended by the analyst's profession of licensure or by the licensing authority in the state in which the psychoanalyst practices.
It is the usual and customary practice of psychoanalysts to refrain from negative charting during psychoanalysis. It is the opinion of this committee that the practice of negative charting results in the creation of progress notes of the sort that degrade psychoanalytic treatment in the manner described in the Charting Psychoanalysis guideline because negative charting focuses constant undue attention on issues which are external to the specific psychoanalytic treatment. The practical and theoretical bases of the position expressed in the Charting Psychoanalysis guideline to explain its four recommendations apply fully to the recommendation herein stated that psychoanalysts refrain from creating progress notes for the purposes of negative charting. The guideline takes no position on the specific content of mental health assessments and recommends that “clinicians maintain customary methods of documenting events in the clinician-patient encounter that fall outside the scope of the psychoanalysis itself. Psychoanalytic practice in these areas may be informed by the guidelines of their particular health profession — medicine, psychology, clinical social work, etc.” (Gray and Cummings, 1995).
This practice guideline was prepared by the Subcommittee on Interacting with Third Parties of the Committee on Peer Review of the American Psychoanalytic Association: Robert R. Cummings, M.D., and Sheila Hafter Gray, M.D. (co-chairs), Joanne Marie Greer, Ph.D., Leon Hoffman, M.D., Roberta K. Jaeger, M.D., Mark Leffert, M.D., Frederic J. Levine, Ph.D., and Richard West, L.C.S.W. It was written for the subcommittee by Robert R. Cummings and Sheila Hafter Gray.
The American Psychoanalytic Association does not intend this practice guideline to state or serve as a standard of practice for mental health care. It is intended as a guideline only. The ultimate judgment regarding a particular clinical decision or method of intervention or overall treatment plan will be made by the practitioner on the basis of the clinical data presented by the patient and the diagnostic and treatment options available in the particular clinical setting. This practice guideline was approved by the Executive Council of the American Psychoanalytic Association on May 2, 1996.