Documenting Patient Requests for Therapy

Patient Assessment and Referral

The American College of Oncology recommends documenting the patient's request for therapy in a brief SOAP note that captures their presenting concern, validates the need for referral, and establishes a clear follow-up plan to ensure they complete the first appointment, including specific symptoms or concerns the patient reports, such as feeling anxious or difficulty coping with stress, and the impact on daily functioning across key domains, with a strength of evidence level of high 1, 2
The Annals of the Rheumatic Diseases guideline suggests including measurable clinical findings, such as vital signs, mental status observations, and screening tool results, like the PHQ-9 for depression or GAD-7 for anxiety, to guide appropriate referral intensity, with a moderate level of evidence 4, 6
The American College of Oncology recommends noting symptom severity level to guide appropriate referral intensity, such as low, moderate, or high intensity services needed, and identifying any barriers to accessing care that may need to be addressed, including transportation, insurance, language, or cultural considerations, with a high level of evidence 1, 2

The American College of Oncology suggests providing patient education about mental health concerns and available resources, using culturally appropriate and linguistically accessible materials, and documenting the specific referral being made, including therapist name, practice, and contact information, with a high level of evidence 1, 2
The Journal of Clinical Oncology guideline recommends establishing a follow-up timeline to verify the patient attended their first therapy appointment, typically within 2-4 weeks, and including contact information for the patient to reach the provider if barriers arise, with a moderate level of evidence 1, 2, 6

The American College of Oncology recommends actively reducing barriers to follow-through by providing written referral information, offering to schedule the first appointment during the visit if possible, and explicitly planning how to verify attendance, with a high level of evidence 1, 2
The Journal of Clinical Oncology guideline suggests using a stepped-care approach when documenting the plan, matching referral intensity to symptom severity, starting with the most effective yet least resource-intensive option appropriate for the patient's presentation, with a moderate level of evidence 1, 2