Live Workshop

Introduction

• The Topic Clinicians Love to Hate
• You’re not crazy, or stupid. You’re just not trained.
• Why document?
• Writing for different “masters”
• Documentation through the lens of medical necessity
• “The Golden Thread” and how it relates to medical necessity
• Documentation as a contribution to good clinical work
• Documentation as protection of income and agent of professional integrity
• Anxiety-reducing answers to common questions.
• Avoiding documentation fatigue

Part 1: How to Write a Treatment Plan 

• Definition of a treatment plan
• Everything that’s needed in a treatment plan and why
• Writing a treatment plan that justifies medical necessity
• Implementing the Golden Thread with case examples
• The Treatment Plan Formula
• Operationalizing the presenting problem
  • How to describe the diagnostic criteria using behavioral language
  • Questions to ask
• Creating a clear connection between the problem, goals, objectives, and interventions
• Protecting client and therapist with a risk assessment
• Evaluating and documenting progress
• Frequency of treatment plans
• How to avoid making yourself crazy writing your treatment plans

Practice writing a treatment plan with review

Part 2: How to Write a Session Note 

• Definition of a session note and how it relates to the treatment plan
• Everything that’s needed in a session note for insurance companies and the law, and why
• Writing a session note that justifies medical necessity using behavioral language and the “golden thread” with case examples
• Maintaining client confidentiality
• Justifying multiple sessions
• How to document changes in treatment plan in the session note

Practice writing a session note and review

Part 3: How to Write Case/Collateral Contact Note, Discharge Summary, & Diagnostic Summary 

• How to Write a Case/Collateral Contact Note
  • The difference between a Case and Collateral Contact Note
  • Everything that’s needed in a Case and Collateral Contact Note and why
  • Relationship to the treatment plan
  • How to write a case/collateral Contact Note that maintains the “golden thread” and justifies medical necessity with case examples
  • Clinical and legal Importance of Case/Collateral Contact Note

• How to Write a Discharge Summary
  • Definition of a discharge summary and how it relates to the treatment plan
  • Everything that’s needed in a discharge summary and why
  • How the discharge summary completes the Golden Thread
  • Legal considerations of a discharge summary
  • To send a termination letter or not

• How to Write an Intake or Diagnostic Summary
  • Establishing the connection between the diagnosis and treatment
  • How to write a diagnostic summary that lays the ground for medical necessity and initiates the Golden Thread
  • What’s needed in a diagnostic summary and why
  • Legal requirements of a diagnostic summary
  • When to write a diagnostic summary

Part 4: Red Flags, Wrap-up 

• What triggers an audit
• How to fail an audit
• Examples of documentation mistakes that can be seen as insurance fraud
• Are paper notes OK? To EHR or not?
• Basic Do’s and Don’ts
• What’s next