Ethical Considerations for Psychotherapists In today’s rapidly shifting social and political landscape, therapists are navigating new challenges when it comes to documentation. Many clinicians find themselves balancing truthful and ethical documentation with the increased need to protect client … [Read more...] about Mental Health Documentation in an Uncertain World
Medicare and Telehealth Coverage: Clearing Up the Confusion
Life before telehealth is a dim memory. You may have given up your office during the pandemic, saw all your clients virtually and now prefer to keep it that way. Or you have a hybrid practice of in-person and virtual services. So, like me, you may have panicked when you heard that Medicare providers … [Read more...] about Medicare and Telehealth Coverage: Clearing Up the Confusion
Essential Admin Forms for Therapists: Stay Legal, Ethical, and Protected
Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. … [Read more...] about Essential Admin Forms for Therapists: Stay Legal, Ethical, and Protected
What do Progress Notes and Dirty Dishes Have in Common?
What do Progress Notes and Dirty Dishes Have in Common? If you don’t write your notes or do your dishes, you can go hungry. Let’s face it, no one likes washing dishes or writing progress notes. They can both pile up faster than rabbits reproduce. But everyone likes it when they’re done. If the … [Read more...] about What do Progress Notes and Dirty Dishes Have in Common?
BODY-DOUBLING: Why it Helps Psychotherapists Get Progress Notes DONE!
Why Body-Doubling Helps Psychotherapists Get Progress Notes DONE! “Exhausting, annoying, demoralizing, and lonely.” This is a common refrain I hear from psychotherapists about documentation. These normal feelings breed avoidance, which leads to falling behind on notes. Behind long enough, it’s … [Read more...] about BODY-DOUBLING: Why it Helps Psychotherapists Get Progress Notes DONE!
Client, Patient, or Name: Which to Use in Mental Health Documentation?
Client, Patient, or Name: Which to Use in Mental Health Documentation? “What is the proper way to refer to a client when writing my notes? Do I use their first name, or do I refer to them as ‘client’ or ‘patient,’ which is their role in our relationship?” I get this question a lot and … [Read more...] about Client, Patient, or Name: Which to Use in Mental Health Documentation?
Documenting Group Therapy
To say that running groups is both challenging and rewarding is like saying that you love to cook but hate to clean up afterwards. The difference is that you can get others to clean up but you still need to write your own notes. REWARDS OF RUNNING GROUP THERAPY There’s truly something magical … [Read more...] about Documenting Group Therapy
Documenting Crisis Management – HELP!
From Chaos to Calm: Effective Crisis Intervention Strategies Naomi Golan, the creator of the Golan Model of Crisis Intervention (1978), describes a crisis as a person who faces a situation in which they feel so overwhelmed they go from a state of “balance to imbalance, and ultimately back … [Read more...] about Documenting Crisis Management – HELP!
Mental Health Documentation and Selfcare
Why in the world would anybody put “selfcare” and “documentation” in the same sentence? Because when therapists start feeling overwhelmed and burnt out the very first thing that’s sacrificed are progress notes! Then the inner Critic berates you by saying, “you’re a bad therapist because you’re … [Read more...] about Mental Health Documentation and Selfcare
7 Documentation Requirements You Can Apply Right Now
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?