Medicare just added Prognosis to its list of documentation requirements. UGH! One more thing to think about and document. But how? What Is a Prognosis? Prognosis refers to making an educated guess about the expected outcome of treatment. Based on the medical model, it’s a prediction of a … [Read more...] about How to Document Prognosis for Mental Health
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!
“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”
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”
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; Essential … [Read more...] about How to Diagnose for Couple’s Counseling