Remember being a teenager at a high school dance? You wanted to cut the rug, but you didn’t know how because you were never taught. If you intuitively knew how to “just dance,” you were golden. Otherwise, you may have either flailed around imitating your friends, or hid in the corner afraid of embarrassing yourself. You liked the music but didn’t know the steps.
Not knowing how to do your documentation is a lot like enjoying the music (doing good therapy) but not knowing how because you were never taught. Using the Documentation Wizard Forms is like having the manual.
Documentation Wizard Clinical Forms guide you, which reduces the anxiety. They are designed around a simple formula that takes the guesswork out of what and how much to write.
TAKE THE CONFUSION OUT OF WRITING NOTES
Most other Session Note templates have prompts for “Clinically Relevant Content” or “Session Content.”
But to a therapist, isn’t everything clinical content? This is why so many therapists either write a book or procrastinate and have 3 months of notes waiting for them to complete.
And when it comes to the Assessment part of the session note, what do you include? There are so many kinds of assessments:
- risk to self and others
- MSE
- effectiveness of treatment
- progress, prognosis
- why a 90837 was necessary
- and more
Which ones go in the Clinical Content box, and will you remember to document each one of these items without a prompt?
That empty box is like being on the dance floor without knowing the music or how to dance!
WHAT ABOUT the GOLDEN THREAD?
The application of the Golden Thread throughout your documenting process is what helps justify medical necessity! Does your current documentation system help you create and maintain the Golden Thread from documenting intake to documenting discharge? Documentation Wizard Clinical Forms do! And if you want to learn even more about how to apply the Golden Thread to justify medical necessity, and how to translate your work into the behavioral language required by insurance companies, check out my Misery or MasterySM online workshop.
IT’S NOT NECESSARY …
… to spend 30 minutes per session note and an hour per treatment plan!
… to agonize that you’re missing required information!
… to worry that you haven’t fulfilled the Golden Thread and justified medical necessity!
… to lose sleep because of a records request.
Instead, the Documentation Wizard Clinical Forms help you:
- Create and maintain the Golden Thread of documentation.
- Remember what to include by breaking down the clinical and administrative requirements into the necessary discrete elements. There’s no guess work!
- Justify medical necessity.
- Enter information quickly with check boxes.
- Provide short narratives so your clinical voice is heard because it should be.
- Satisfy all billing and clinical needs.
- Minimize the time you spend writing your notes.
- Reduce your anxiety.
Because all the content needed has been distilled into separate sections, the formatting is deceivingly simple. There are no empty boxes to fill with “relevant content,” leaving you to wonder what and how much to write. The Documentation Wizard Clinical Forms provide prompts that, when followed, help you create a cohesive narrative without over-telling the details of the story and spending a lifetime doing it.
MY STRUGGLE AS A THERAPIST
My first clinical supervisor couldn’t understand how I could be a good clinician and so bad at documentation. (Sound familiar?) I told him I wasn’t taught the dance steps!
After being promoted to supervisor (for my clinical skills) I was tasked to help create the clinic’s first digital documentation system — and then teach my supervisees how to use it. Holy cow! For someone who labored over her own documentation, this was a daunting struggle… and a big win. I know the problems from multiple sides and developed forms that solve the problems. All that I learned from this experience, and more has been captured in the Documentation Wizard forms. It is why my forms are unique.
PROOFED AND APPROVED!
These forms are not an accumulation of patchwork changes passed down from one well-meaning clinician to the next. They’ve been reviewed, tested, and proven to work. When used well, they contribute to clinical thinking, help you fulfill your professional standards of care, and pass audits.
The forms are simple to use but not simplistic. Creating these copyrighted documents took 1000s of hours of work. Having multiple attorneys, countless clinicians, and a bio-ethicist review the forms is an ongoing significant investment, but necessary to achieve clinical and regulatory accuracy and excellence.
A WORTHWHILE INVESTMENT
Buying the Documentation Wizard Clinical Forms is less expensive than paying a monthly subscription for a cloud-based practice management system. Using them for one year ends up being less than $24 per month. If you use them for four years, it’s equivalent to less than $6 a month!
Once purchased, your forms can be downloaded to your computer immediately. But never worry about losing your originals because you always have access to them by logging into your online account. You are free to customize these forms to suit your practice needs. They cannot be shared with or distributed to others, but they can be uploaded or integrated into many commonly used practice management systems.
You know what happened in your session. You just don’t know what, how much, or where to write the information — yet.
Let Documentation Wizard Clinical Forms help improve your note writing, contribute to clinical thinking, reduce your anxiety, boost your confidence, and do it all faster and easier. Let’s dance!