7 Documentation Requirements You Can Apply Right Now Here are some common questions and answers when it comes to mental health documentation requirements. 1. Question: Are notes for private pay clients the same as for insurance? Answer: Yes – justifying medical necessity has become the … [Read more...] about 7 Documentation Requirements You Can Apply Right Now
Challenges with AI in Progress Notes
Insights into using AI from a Mental Health Therapist and Documentation Expert In an era where technology permeates every aspect of our lives, it's no surprise that artificial intelligence (AI) is finding a home in mental health care. One area where AI is gaining greater use is in the creation of … [Read more...] about Challenges with AI in Progress Notes
Question & Answer: Intake Summary
Question & Answer: How do I write an Intake Summary without violating client confidentiality? QUESTION I'm struggling with how to effectively document in a manner that satisfies "medical necessity" requirements while also protecting the privacy of my clients. I understand how to keep … [Read more...] about Question & Answer: Intake Summary
How to Opt-Out of Medicare and Still Get Paid
Your Guide to Opting Out of Medicare as a Mental Health Provider: and How Medicare Clients Can Get Reimbursed Yes, it is possible to see a Medicare client, get your full fee, and for the client to not have to pay for your service. The process isn’t even that difficult. Unlike most things … [Read more...] about How to Opt-Out of Medicare and Still Get Paid
The Ethics of Other People Writing Your Treatment Plan
The Ethics of Other People Writing Your Treatment Plan QUESTION Is it ethical for one therapist to write a Treatment Plan for another therapist to use? At my group practice, I’m often asked as a licensed therapist to do an Intake and write the Treatment Plan to hand off to a master’s … [Read more...] about The Ethics of Other People Writing Your Treatment Plan
Timely Progress Note Completion in Mental Health Documentation
The most frequently asked question I get in my documentation course is, “What is the deadline for progress note completion? This is a frustrating question because like so many aspects of mental health, there is no definitive answer. Understanding the Confusion Our professional codes of … [Read more...] about Timely Progress Note Completion in Mental Health Documentation
Can You Use AI for Mental Health Progress Notes?
Can You Use AI for Mental Health Progress Notes? Although AI has been around for quite a few years, it recently burst onto the scene like fireworks and is causing a lot of noise. Some psychotherapists are already raving about how it cuts down on the time it takes to write their notes and … [Read more...] about Can You Use AI for Mental Health Progress Notes?
Can You Combine the Intake Summary and the Diagnostic Session Note?
QUESTION: Can You Combine the Intake Summary and the Diagnostic Session Note? My EHR combines the Intake Summary and the Diagnostic Session Note and calls it the Intake Session Note. What do you think of combining them? ANSWER I prefer the documents to be separated, but there is no … [Read more...] about Can You Combine the Intake Summary and the Diagnostic Session Note?
Should I Document Medications on Progress Notes?
QUESTION: Should I Document Medications on Progress Notes? I have heard from others, who consider themselves Medicare documentation experts, that it is unnecessary to document anything about psychiatric medication compliance and effectiveness. They advise against it as it is the prescriber's job, … [Read more...] about Should I Document Medications on Progress Notes?