Do psychotherapists need to use EMRs or EHRs for writing clinical notes?The short answer is, “no.” Not yet. And maybe-not-ever. There are other (better) tools psychotherapists can use for writing clinical notes and documenting medical necessity.Really? Yes!To understand the answer, it’s … [Read more...] about EMRs and EHRs and Online Programs, oh my!
Documenting Mental Health CPT Code 90837
Many therapists provide a 60 minute session but afraid of triggering an audit, they do not bill for it. We love our work but unless we are independently wealthy, we need to be paid to do it. We don’t get paid for providing psychotherapy. We get paid for our time. Psychotherapy is what we spend our … [Read more...] about Documenting Mental Health CPT Code 90837
“I Love Writing Psychotherapy Notes”
If you ... experience doing your notes as a never-ending and tedious task, find it clinically irrelevant, andwould rather clean the bathroomI get it! You...don't know what or how much to write.resent the time it takes.wonder how to maintain client confidentiality.worry about legal issueslose sleep … [Read more...] about “I Love Writing Psychotherapy Notes”
How to Document “Low Self-Esteem”
Esther Perel's definition of self-esteem is, "Seeing yourself as a flawed person, and still holding yourself in high regard." It's a common occurrence that clients come to treatment feeling broken and hopeless, reporting low self-esteem, and not believing they will ever be able to hold themselves in … [Read more...] about How to Document “Low Self-Esteem”
I Don’t Take Insurance. Do I Still Need to Write Treatment Plans and Progress Notes?
Yes! Documentation has always been a standard in our profession so it's required. And here are other good reasons why.These are the "negative" or the cover-your-butt reasons to maintain good documentation.Remember -- IF IT'S NOT DOCUMENTED IT DIDN'T HAPPEN.On the positive side, writing … [Read more...] about I Don’t Take Insurance. Do I Still Need to Write Treatment Plans and Progress Notes?
When a Client Wants SSI or SSDI
A therapist recently asked me how to handle a request from the Social Security Administration for the medical records of a client she hadn’t seen in several months and only for two sessions. The request was accompanied by a signed release so it was legitimate.Not having access to the client’s … [Read more...] about When a Client Wants SSI or SSDI
How to Diagnose for Couple’s Counseling
Many couples presenting for couple’s counseling do not fit into a billable diagnostic category. How do I write a treatment plan and session notes -- or bill the insurance company if I don’t have a diagnosis?I’ve been getting a version of this question in my workshops, Misery or Mastery; Documenting … [Read more...] about How to Diagnose for Couple’s Counseling