F68.1 supports documentation after a clinician diagnoses factitious disorder
Factitious disorder is documented in ICD-10-CM under F68.1. More specific codes may be used when the clinical presentation is predominantly psychological, predominantly physical, or includes both psychological and physical symptoms. Diagnosis selection remains the clinician’s responsibility. AutoNotes can help organize documentation, but it does not assign diagnoses or replace clinical judgment.
For behavioral health clinicians, F68.1-related documentation often appears in assessments, progress notes, psychiatric evaluations, care coordination notes, and treatment plans. The record may need to describe reported symptoms, observed inconsistencies, collateral information, medical or behavioral health history, risk considerations, and the clinician’s rationale for ongoing assessment or treatment.
This diagnosis can be clinically sensitive. Documentation should be specific, neutral, and behavior-based. Instead of writing that a client is “faking,” a stronger clinical note describes what was reported, what was observed, what information was reviewed, and what clinical questions remain.
ICD-10-CM codes commonly associated with factitious disorder
The broader ICD-10-CM category for factitious disorder is F68.1. Depending on the current code set, payer requirements, and the clinician’s diagnostic determination, related codes may include:
- F68.10 — Factitious disorder, unspecified
- F68.11 — Factitious disorder with predominantly psychological signs and symptoms
- F68.12 — Factitious disorder with predominantly physical signs and symptoms
- F68.13 — Factitious disorder with combined psychological and physical signs and symptoms
Clinicians should verify the most current ICD-10-CM code set, organizational policy, and payer requirements before finalizing a diagnosis code. In many behavioral health settings, the documentation burden is not only choosing the code. The harder task is writing a clear note that supports the clinical reasoning without overstating certainty.
Clinical documentation should separate reported symptoms from observed facts
Factitious disorder documentation often involves complex clinical information. A client may report symptoms, disability, medical events, trauma history, psychiatric symptoms, or treatment experiences that are difficult to verify in the moment. A careful note separates the client’s report from the clinician’s observations and any collateral or record-based information.
For example, a progress note might distinguish between:
- Client report: “Client reported three emergency department visits in the past month due to fainting episodes.”
- Clinical observation: “Client appeared alert and oriented during session and did not display visible distress while describing symptoms.”
- Collateral or records: “With authorization, clinician reviewed discharge paperwork from one hospital visit.”
- Clinical formulation: “Further assessment indicated due to discrepancy between reported frequency of events and available records.”
This structure helps the note remain clinically useful. It also reduces the risk of language that sounds accusatory or unsupported. If the diagnosis is provisional, document it that way according to your setting’s standards.
Common documentation contexts for F68.1
Clinicians may encounter F68.1-related documentation in several behavioral health workflows. The content and level of detail will vary by setting, scope of practice, and available information.
Intake and diagnostic assessment
During an intake, the clinician may document the client’s presenting concerns, symptom history, prior diagnoses, treatment episodes, medication history, medical conditions, and current functional impairment. If factitious disorder is being considered, the assessment should describe the basis for that clinical question rather than jumping to a conclusion.
Relevant details may include patterns in symptom reporting, repeated treatment-seeking, inconsistencies across records, self-reported medical procedures, unexplained worsening of symptoms, or strong identification with the patient role. The note should also document differential considerations, such as somatic symptom disorder, illness anxiety disorder, malingering, trauma-related symptoms, personality pathology, substance use, psychosis, mood disorders, neurocognitive concerns, or medical conditions that require evaluation.
Therapy progress notes
In ongoing therapy, the progress note usually needs to capture interventions, client response, progress toward treatment goals, risk factors, and the plan for continued care. For a client diagnosed with or being assessed for factitious disorder, the note may also document work on emotional triggers, interpersonal stressors, attachment patterns, distress tolerance, insight, and readiness for coordinated care.
A progress note does not need to repeat the entire diagnostic history each session. It should include the clinically relevant details from that encounter. If the session focused on a recent medical visit, the note might document the client’s report, the therapist’s intervention, the client’s response, and any plan for coordination with medical providers, if authorized.
Care coordination and collateral contact
Factitious disorder may involve multiple professionals, including primary care providers, psychiatrists, specialists, hospitals, case managers, and family members. Documentation should identify who was contacted, the client’s authorization status, the purpose of the contact, information received, and how that information affected the treatment plan.
For example, a care coordination note may state that the clinician received a signed release and spoke with the client’s primary care provider about treatment history and current safety concerns. The note should avoid including unnecessary details that do not support care.
What to include in a clinically useful F68.1 note
A strong note gives another qualified clinician enough information to understand what happened, what the clinician assessed, and what will happen next. For factitious disorder, clarity matters because the diagnosis may involve sensitive interpretations of behavior and motivation.
Consider documenting the following when clinically relevant:
- Presenting symptoms and the client’s description of onset, frequency, severity, and impairment
- Observed affect, behavior, thought process, insight, judgment, and consistency of presentation
- Relevant medical, psychiatric, trauma, substance use, and treatment history
- Collateral information or record review, including authorization and source
Additional elements may include risk assessment, safety planning, diagnostic impressions, differential diagnoses, interventions used, client response, treatment goals, care coordination steps, and follow-up plan. If the client’s symptoms involve possible self-injury, unnecessary medical intervention, medication misuse, or risk to another person, the note should reflect appropriate assessment and next steps within the clinician’s role.
Language choices that reduce ambiguity
Factitious disorder documentation benefits from precise wording. Neutral language protects clinical clarity and supports a more therapeutic stance. It also helps avoid chart entries that read as judgmental rather than evidence-based.
Instead of writing: “Client lied about symptoms.”
Consider: “Client reported seizure activity occurring daily. Available neurology records reviewed with authorization did not confirm seizure diagnosis. Clinician explored client’s distress related to feeling dismissed by medical providers.”
Instead of writing: “Client is attention-seeking.”
Consider: “Client described increased support from family during periods of acute medical concern and reported fear of being alone when symptoms decrease.”
Instead of writing: “Symptoms are fake.”
Consider: “Reported symptom pattern remains unclear. Clinician will continue assessment and coordinate with medical provider with client consent.”
This approach does not soften clinical reasoning. It makes the record more specific.
Example SOAP note for factitious disorder documentation
The example below is for documentation structure only. It is not a diagnostic recommendation, and it should not be copied into a client record without clinical review and editing.
S — Subjective: Client reported ongoing abdominal pain and stated that symptoms have led to three urgent care visits in the past six weeks. Client expressed frustration that “no one can find what is wrong” and reported increased anxiety when providers suggest stress may contribute to symptoms. Client denied current suicidal ideation, homicidal ideation, or intent to self-harm.
O — Objective: Client arrived on time, was oriented x4, and participated throughout session. Affect was anxious and tearful when discussing medical providers. Client spoke in detail about prior testing and used medical terminology. No acute impairment observed during session. Clinician reviewed one discharge summary provided by client.
A — Assessment: Client continues to experience significant health-related distress and interpersonal strain related to reported medical symptoms. Documentation reviewed to date does not fully clarify reported symptom history. Factitious disorder remains part of the diagnostic formulation based on clinician assessment; continued evaluation and care coordination are indicated. Clinical judgment required before finalizing or changing diagnosis.
P — Plan: Continue weekly therapy focused on emotional regulation, distress tolerance, and patterns related to medical reassurance-seeking. Obtain signed release to coordinate with primary care provider, if client agrees. Monitor risk, functional impairment, and changes in reported symptoms. Reassess treatment goals next session.
Treatment planning considerations for factitious disorder
Treatment planning should be individualized and should reflect the client’s symptoms, risk level, insight, co-occurring conditions, and care setting. Many clinicians focus on maintaining engagement while addressing distress, interpersonal patterns, safety, and coordination with other providers.
Potential treatment plan elements may include goals such as improving emotional awareness, reducing harmful or unnecessary medical behaviors, strengthening coping skills, improving communication with providers, and addressing co-occurring anxiety, depression, trauma symptoms, or personality-related patterns when present.
Interventions may include supportive therapy, cognitive behavioral strategies, motivational interviewing techniques, psychoeducation, coordination with medical providers, safety planning, and skills-based work. The plan should document how progress will be measured. Examples include fewer crisis-driven medical contacts, improved use of coping strategies, increased insight into triggers, or more consistent participation in coordinated care.
How AutoNotes helps clinicians draft F68.1 documentation
AutoNotes supports documentation by helping clinicians turn session details into structured, editable drafts. For F68.1-related notes, that structure can be especially helpful because the record often needs to distinguish reported symptoms, observations, collateral information, interventions, assessment, and plan.
AutoNotes does not diagnose clients, assign ICD-10 codes, or determine medical necessity. The clinician remains responsible for selecting diagnoses, reviewing the note, editing for accuracy, and finalizing the clinical record.
Clinicians can use AutoNotes to draft:
- SOAP, DAP, BIRP, and other progress note formats
- Intake and assessment documentation
- Treatment plan drafts with goals, objectives, and interventions
- Care coordination and collateral contact notes
For busy therapists, counselors, psychologists, social workers, and psychiatrists, the benefit is a faster starting point. Instead of building every note from a blank screen after a full day of sessions, clinicians can begin with an organized draft and then apply their clinical judgment.
Use F68.1 documentation templates while keeping clinical control
Factitious disorder documentation requires care, precision, and a clear record of clinical reasoning. Templates and AI-assisted note drafts can help maintain consistency, but they should support the clinician’s thinking rather than replace it.
If you want a faster way to create structured, editable progress note drafts for complex behavioral health documentation, start your free trial with AutoNotes. Review each draft, adjust the language to match the session, and finalize the note using your own clinical judgment.
