Documentation Wizard, LLC

Documenting Medical Necessity for Psychotherapists

Why Your Mental Status Exam Needs a Cultural Lens (And How to Add One)

After twenty years of teaching clinical documentation, I've noticed something important: even the most well-intentioned clinicians can miss crucial cultural context in their mental status exams. This isn't about pointing fingers. We are always learning how to navigate our increasingly diverse client … [Read more...] about Why Your Mental Status Exam Needs a Cultural Lens (And How to Add One)

The Informed Consent Conversation: Building Trust, Setting Boundaries, and Getting Paid Without Guilt

Getting paid without guilt starts before your first session even begins. Most therapists treat informed consent like annoying paperwork to get through before the “real work” of therapy begins.  But informed consent is not a signature. It’s a process. Done well, it protects your clients, … [Read more...] about The Informed Consent Conversation: Building Trust, Setting Boundaries, and Getting Paid Without Guilt

AI in Psychotherapy: Disclosure or Consent?

Let’s break down the gray areas of using Artificial Intelligence that may keep you up at night. Like many therapists, you're thinking about using Artificial Intelligence (AI) tools in your practice or are already using them. And you're wondering what you need to tell your clients about how you use … [Read more...] about AI in Psychotherapy: Disclosure or Consent?

Mental Health Documentation in an Uncertain World

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

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?

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?

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?

Should I Use a Treatment Planning Book?

Should I Use a Treatment Planning Book? Like many answers to questions about mental health, the answer to this common question on whether or not you should use a treatment planning book is a bit more complicated than a simple yes or no. When discussing treatment plans during my trainings, … [Read more...] about Should I Use a Treatment Planning Book?

I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task

Q: I love being a therapist, but I hate writing progress notes and sometimes can’t bring myself to do it. I know it’s risky not to write them. Is there a way to make this task less onerous? A: Every therapist knows that avoiding progress notes puts their practice in jeopardy. But of the thousands … [Read more...] about I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task