Wiki Interactive Therapy for children

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In talking with my dr's I code for, it is my understanding that it is very common for child psychiatrists to use play therapy as a common method of therapy. Evidentally through this method, it helps the child to relax in the enviroment and loosen up and talk vs just sitting on a chair and talking face to face with dr. With that said, what kind of notation do you look for in the note to support the documentation requirement of the record needing to indicate why the person being evaluated does not have the ability to interact through normal verbal channels, etc.

I would think it is safe to say some of the kids do have the ability to talk through "normal channels" but I would venture to say the dr gets alot further with the play method.

Thoughts? Examples? Recommendations?
 
Usually, you will see notation of the child's age (which will often reflect the fact that the child is too young to gain benefit from regular talk therapy - i.e. insight oriented, behavior modifying, etc.). You will also see documentation reflecting the type of psychotherapy utilized (in this case, the type should be "play therapy") as well as any specific tools used (i.e. board game, sand box, finger paints, etc.). The counselor may also cite specific diagnostic reasoning (i.e. autism, mental retardation, etc.) as to why play therapy may be used. Hope this is helpful . . .

Wendy R. Ley, LCSW, CPC-A
 
The more documentation the better...is what I have been told. So, if the provider is doing play therapy to help the child be more comfortable and thus open up. Put that information in the documentation. And then document the specific tools, as Wendy said, and how the child used those tools, did they play agressivly with no remorse. Most of the time a child will play with something they way they have been treated!
Hope this helps.
 
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