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 reward … [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 easy … [Read more...] about BODY-DOUBLING: Why it Helps Psychotherapists Get Progress Notes DONE!
Challenges with AI in Progress Notes
Insights into using AI from a Mental Health Therapist and Documentation ExpertIn 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
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 how … [Read more...] about Can You Use AI for Mental Health Progress Notes?
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, not … [Read more...] about Should I Document Medications on Progress Notes?
Mental Health Documentation for Worker’s Compensation
Mental Health Documentation for Worker’s CompensationA 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 Plan, … [Read more...] about Mental Health Documentation for Worker’s Compensation
How to Document for Tele-Mental Health During the Covid-19 Pandemic
Adjusting to TelehealthWe’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 tele-mental … [Read more...] about How to Document for Tele-Mental Health During the Covid-19 Pandemic
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 answer, it’s … [Read more...] about EMRs and EHRs and Online Programs, oh my!
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?
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