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
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
Private practice therapists juggle multiple roles – clinician, business owner, and administrator. But just like progress notes and treatment plans, running a private practice wasn’t taught in grad school. From clinical to legal and ethical issues to marketing and billing, the workload can be … [Read more...] about Essential Admin Forms for Therapists: Stay Legal, Ethical, and Protected
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?
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
Mental Health Documentation for Worker’s Compensation
Mental Health Documentation for Worker’s Compensation A therapist recently asked me how to document for a Worker’s Compensation claim. Some companies will accept a summary of treatment. Most will want the client’s full record. That will include the Diagnostic Assessment, Treatment … [Read more...] about Mental Health Documentation for Worker’s Compensation
Overview of Creating and Integrating Forms into Simple Practice
[Beth Rontal ] Welcome everyone for my first live Facebook. So we're very happy to have you here. I am Beth Rontal, the Documentation Wizard and LICSW. And I am welcoming Frances Harvey from My Solution Services. And we're gonna give an overview of how to customize, create, and integrate your … [Read more...] about Overview of Creating and Integrating Forms into Simple Practice
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
How to Document Changes in Treatment During Covid-19 Without Writing Another Plan
Private practice therapists are expected to write a new treatment plan once a year. What happens when your well thought out plan gets thrown to the wind before it's time for an update? This scenario may be happening right now since the sudden outbreak of the Covid-19 pandemic. Problems, goals, and … [Read more...] about How to Document Changes in Treatment During Covid-19 Without Writing Another Plan
How to Document for Tele-Mental Health During the Covid-19 Pandemic
Adjusting to Telehealth We’re all trying to adjust to a new way of living and providing mental health services. I’m going to help you navigate the needs for tele-mental health documentation during the Corona virus pandemic. Most insurance companies are now finally on board with offering … [Read more...] about How to Document for Tele-Mental Health During the Covid-19 Pandemic
Can Mental Health Providers Charge For Phone Calls?
Like most answers I give regarding being a mental health therapist and having a private practice, “yes” and “no.” WHY SHOULD MENTAL HEALTH PROFESSIONALS CHARGE FOR PHONE CALLS? Phone calls can take a lot of time and time is what we’re paid for. If you don’t charge for these phone calls, you are … [Read more...] about Can Mental Health Providers Charge For Phone Calls?
Are Discharge Summaries Mandatory?
Do you need to write a discharge summary as a mental health provider? Yes and no. Confusing? Definitely. That’s because the standards are not consistent from one insurance company to the next. Here’s what I can tell you: Discharge Summaries for Medicaid Medicaid requires … [Read more...] about Are Discharge Summaries Mandatory?
EMRs and EHRs and Online Programs, oh my!
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 … [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 bathroom I 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 … [Read more...] about “I Love Writing Psychotherapy Notes”