Record-Keeping for Partial Hospitalization Recovery Programs

In the world of behavioral health, Partial Hospitalization Programs (PHPs) occupy a high-stakes “middle ground.” Because your programs provide intensive, hospital-level care while allowing patients to return home at night, the documentation requirements are significantly more rigorous than standard outpatient therapy.

When an organization provides Partial Hospitalization services, every entry in a patient’s chart must connect back to a central clinical narrative. This traces back to the intake assessment that informs the treatment plan, then the treatment plan goals must be reflected in every single daily progress note.

Here are the critical record-keeping pillars every PHP administrator must maintain to protect the organization from audits and liability claims.

1. Physician Certification and Necessity

Unlike standard counseling, a PHP requires a high level of medical oversight. To qualify for insurance coverage (and to defend against negligence), the records must prove that the patient requires this level of care.

A licensed physician must certify on Day 1 that the patient would require inpatient hospitalization if not for the PHP. Records must show periodic recertification (usually at the 18-day mark and every 30 days thereafter) to prove the patient still meets the clinical threshold for intensive treatment. Documentation must clearly explain why the patient cannot be safely treated in a lower level of care, such as Intensive Outpatient (IOP) or traditional weekly therapy.

2. 20-Hour Time and Attendance

One of the most common reasons for insurance “clawbacks” (where the insurer demands money back) is a failure to prove the patient received the required hours of service. Most payers require a minimum of 20 hours of therapeutic programming per week (typically 4-6 hours per day). To facilitate proving this, your records should include exact sign-in and sign-out times for every patient. Similarly, lunch breaks, transit time, and recreational “hang-out” time do not count toward the 20-hour requirement. Your logs must distinguish between “clinical hours” and “support hours.”

3. Daily Progress Notes

In a PHP, a weekly summary might leave gaps that an insurance carrier can use not to fund claims. Instead, try a progress note for every single day the patient is on-site. To stand up to an audit, these notes must follow a professional format (like SOAP or DAP) and include these things:

• Specific Interventions: What clinical modality was used? (e.g., “Conducted CBT-based group session on identifying cognitive distortions.”)

• Patient Response: How did the patient engage? (e.g., “Patient actively participated, sharing two personal examples of ‘all-or-nothing’ thinking.”)

• Risk Assessment: Every daily note should include a brief assessment of safety risk (suicidality, self-harm, or threats to others).

• Try to make these detailed, and make sure that you go beyond “client sat in group”! You want the insurance company, in case of any claims, to see that you know what’s going on with the patient.

4. Treatment Plan Reviews

Because PHP is an intensive, short-term “stabilization” level of care, the treatment plan cannot be static. Many accrediting bodies and insurance carriers require the team (psychiatrist, therapist, and nurse) to review and update the treatment plan regularly. A good rule of thumb is to think that the plan should be updated every 72 hours. In addition, documentation should show progress, or lack thereof, toward specific, measurable goals. If a patient is not progressing, the records should show that the team adjusted the treatment plan accordingly.

5. HIPAA Compliance and “Duty to Warn”

Partial Hospitalization involves highly sensitive Protected Health Information (PHI). Make sure you store records in a HIPAA-compliant Electronic Health Record (EHR) with restricted access.

In addition, while HIPAA protects privacy, the “Duty to Warn” requires documentation of when and why a provider broke confidentiality due to a “good faith belief” that the patient posed an imminent threat to themselves or others. Your logs must show the professional judgment used in these high-stakes moments.

Poor record-keeping is one of the biggest reasons for denied insurance claims and one of the biggest weaknesses in a professional liability lawsuit. When an organization standardizes its documentation by conducting regular internal “chart audits”, it can help create a safety net that protects both the staff and the individuals in recovery.