Live Group Training
Misery or Mastery®
Essential Documentation for Psychotherapists
…empowering mental health professionals to translate their clinical intuition into effective documentation
The Live Documentation Wizard training provides a comprehensive, practical, and engaging approach to teaching clinical documentation skills to groups of all sizes. This training reduces documentation-related anxiety, strengthens compliance, and helps ensure that your team meets professional and regulatory standards.
The Misery or Mastery®: Essential Documentation for Psychotherapists training teaches a step-by-step approach to guide you through treatment plans, progress notes, case and collateral notes, diagnostic summaries, and discharge summaries. This process helps take the struggle out of paperwork so your team can put their focus where they really want — on their clients.
The 6-hour training is designed for group practices, clinics, agencies, hospitals, and behavioral health programs seeking consistent, clear, and defensible clinical documentation.
What’s Included
Participants receive:
• The Workshop Manual with the PowerPoint slide deck to take notes and use as a reference
• Practice treatment plan and practice progress note form used during the training
• Access to Beth’s Facebook group, Misery or Mastery: Documenting Medical Necessity for Psychotherapists, for ongoing support
Continuing Education Credits may be possible for psychologists, social workers, marriage and family therapists, and mental health counselors. The sponsoring organization is responsible for obtaining CE credit approval, and Beth is happy to provide any information required.
Your Clinicians Will Learn to:
Apply the clinical documentation process for writing successful notes, treatment plans, case consults, discharge and intake summaries -to Medicare standards.
Demonstrate how to translate your work into the behavioral language required by insurance companies while organizing your clinical thinking through structured documentation
Document medical necessity using the Golden Thread
Identify Red Flags that could trigger an audit and result in insurance recoupment
Training Objectives
- Apply the clinical documentation process for writing successful session notes, treatment plans, case consults, discharge, and intake summaries
- Demonstrate how to translate your work into the behavioral language required by insurance companies
- Apply the Golden Thread to justify medical necessity
- Identify Red Flags that could trigger an audit and result in an insurance recoupment
Training Schedule
Introduction
- The Topic Clinicians Love to Hate
- You’re not crazy, or stupid. You’re just not trained.
- Why document?
- Writing for different “masters”
- Documentation through the lens of medical necessity
- The Golden Thread and how it relates to medical necessity
- Documentation as a contribution to good clinical work
- Documentation as protection of income and agent of professional integrity
- Anxiety-reducing answers to common questions
- Avoiding documentation fatigue
Part 1: How to Write a Treatment Plan
- Definition of a treatment plan
- Everything that’s needed in a treatment plan and why
- Writing a treatment plan that justifies medical necessity
- Implementing the Golden Thread with case examples
- The Treatment Plan Formula
- Operationalizing the presenting problem
- How to describe the diagnostic criteria using behavioral language
- Questions to ask
- Creating a clear connection between the problem, goals, objectives, and interventions
- Protecting client and therapist with a risk assessment
- Evaluating and documenting progress
- Frequency of treatment plans
- How to avoid making yourself crazy writing your treatment plans
- Practice writing a treatment plan with review
Part 2: How to Write a Progress Note
- Definition of a progress note and how it relates to the treatment plan
- Everything that’s needed in a progress note for insurance companies and the law, and why
- Writing a progress note that justifies medical necessity using behavioral language and the “golden thread” with case examples
- Maintaining client confidentiality
- Justifying multiple sessions
- How to document changes in treatment plan in the progress note
- Practice writing a progress note and review
Part 3: How to Write Case/Collateral Contact Note, Discharge Summary, & Diagnostic Summary
- How to Write a Case/Collateral Contact Note
- The difference between a Case and Collateral Contact Note
- Everything that’s needed in a Case and Collateral Contact Note and why
- Relationship to the treatment plan
- How to write a Case/Collateral Contact Note that maintains the “golden thread” and justifies medical necessity with case examples
- Clinical and legal importance of Case/Collateral Contact Notes
- How to Write a Discharge Summary
- Definition of a discharge summary and how it relates to the treatment plan
- Everything that’s needed in a discharge summary and why
- How the discharge summary completes the Golden Thread
- Legal considerations of a discharge summary
- To send a termination letter or not
- How to Write an Intake or Diagnostic Summary
- Establishing the connection between the diagnosis and treatment
- How to write a diagnostic summary that lays the ground for medical necessity and initiates the Golden Thread
- What’s needed in a diagnostic summary and why
- Legal requirements of a diagnostic summary
- When to write a diagnostic summary
Part 4: Red Flags, Wrap-up
- What triggers an audit
- How to fail an audit
- Examples of documentation mistakes that can be seen as insurance fraud
- Are paper notes OK? To EHR or not?
- Basic Do’s and Don’ts
- What’s next
Instructor
Beth Rontal, MSW, LICSW, is a nationally recognized and engaging speaker on mental health documentation for private practice clinicians and those in agency settings. She mastered her teaching skills with thousands of hours supervising and training clinicians at an agency for 11 years. Her Misery & Mastery ™ trainings and documentation forms have been used world-wide. Beth works with both emerging and seasoned mental health professionals, agencies, clinics, group practices, and hospitals. Beth writes biogs on clinical documentation, cochairs the NASW Private Practice Shared Interest Group, and has a private practice in Brookline, MA specializing in working with people who struggle with emotional eating.
Past Live Trainings
2025
- Friday, June 27, 2025 – Michigan Child & Adolescent Health Center, Live Webinar
- Friday, April 18, 2025 – Full Force Foundation, San Antonio, TX, Private
- Friday, April 11, 2025 – Private Live Webinar
- Friday, April 4, 2025 – Documentation Wizard Live Webinar
2024
- Wednesday, September 18, 2024 – Lakeside Counseling, Live Webinar
- Friday, May 3, 2024 – Documentation Wizard Live Webinar
2023
- October 27, 2023 – CE Learning Systems, Live Training
- October 20, 2023 – Therapy Training, Boston, In-person & Virtual
- September 13, 2023 – Southern Indian Health Council, California, Virtual, Private
- August 2, 2023 – Child and Adolescent Health Center Program, Michigan, Virtual, Private
- May 12, 2023 – Documentation Wizard Live Webinar
RESEARCH
There are a variety of reputable websites regarding best practice standards for documenting medical necessity. A few select sites include: Association for Behavioral Health Care; Massachusetts Standardized Documentation Project http://bit.ly/2NdzDET; Medical Documentation for Behavioral Health Practitioners 2015 at https://go.cms.gov/2EkA9OV; and a specific social work resource book Sidell, Nancy L. Social Work Documentation; a Guide to Strengthening Your Case Recording, NASW Press, Washington, DC, 2011. & revised edition, 2015 http://bit.ly/2Eh5yBt
TARGET AUDIENCE
social workers, psychologists, marriage and family therapists, mental health counselors, creative arts therapists, addictions professionals, and other interested human service staff.
CONTENT LEVEL
Beginning, Intermediate, Advanced
Bring This Training to Your Team
Beth can tailor the training to your team’s experience, documentation challenges, and clinical setting. Whether delivered in person or as a live webinar, your clinicians will leave with practical, clinically grounded skills they can begin using immediately.
Ready to begin the conversation?
Beth would love to meet with you to discuss your group or agency’s documentation needs. Click below to complete a short form and schedule a time that works for you.