Online Training

Unlimited access to a series of 6 videos for one year.

MODULE 1: YOU'RE NOT A BAD THERAPIST. YOU'RE JUST NOT TRAINED (30 minutes)

• The 3 causes of “documentation anxiety”
• How to stop documentation anxiety from becoming “documentation trauma”
• What our codes of ethics say about documentation
• Insurance and private pay therapists – same documentation standards?
• Documentation as protection of income and agent of professional integrity
• Anxiety-reducing answers to common questions.
• Documentation as a contribution to good clinical work

MODULE 2: DEFINITIONS AND CONTEXT  (15 minutes)

• Documentation through the lens of medical necessity
• The "Golden Thread” and its role in justifying medical necessity
• Conceptualizing therapy as a single-case experiment to guide treatment
• Using diagnosis as the hypothesis and progress documentation as the experimental outcome
• Establishing the connection between the diagnosis and treatment
• Functions of documentation
• The complexities and clinical challenges of writing for different audiences
• The significance of clinical intuition in the documentation process

MODULE 3: THE TREATMENT PLAN (3 hours 15 minutes)

• Administrative and clinical requirements
• Writing a treatment plan that justifies medical necessity
• How the treatment plan describes the experimental process
• The Treatment Plan Formula
  • Implementing the Golden Thread with case examples
  • Creating a clear connection between all elements of the plan
• How to operationalize the treatment plan
  • Why using behavioral language makes sense clinically
  • Including clients in the treatment planning process.
  • Questions to ask
• The challenges of and solutions for creating realistic and measurable goals
• The “rule of 3”
• The value of documenting barriers to treatment
• Protecting client and therapist with a risk assessment
• The debate over documenting medications and best practice
• Evaluating and documenting progress
• Deadline for writing treatment plans
• Shedding light on treatment plan frequency
• How to avoid making yourself crazy writing your treatment plans

Implementing the golden thread with a Treatment Plan Practice Session

MODULE 4: THE PROGRESS NOTE (1 hour 30 minutes)

• Administrative and clinical requirements of the progress note, including telehealth documentation
• The role of the progress note in advancing the golden thread
• Documenting each session in the experimental process and how it relates to the treatment plan
• The controversy between using checkboxes and narratives
• Guidelines for determining when to be vague and when to be specific
• Balancing client confidentiality with clarity about what happened during the session
• The 6 different assessments in the progress note
• The role of the risk assessment; not just for suicide, homicide, and violence
• The importance of documenting sleep issues
• Writing interventions without using psychobabble
• The continuing debate over documenting medications and best practice
• How to document even the slightest progress
• Justifying “extended-time” and multiple sessions of the week
• Debunking the myth of the 24-hour completion rule

Implementing the golden thread with a Progress Note practice session

MODULE 5: THE CLINICAL DOCUMENTATION NO ONE TALKS ABOUT (45 minutes)

• The Collateral Contact Note
  • Administrative and clinical requirements
  • Clinical and legal imperatives of writing the collateral contact note
  • Maintaining the golden thread and justifying medical necessity with case examples

• The Discharge Summary
  • Administrative and clinical requirements
  • How the discharge summary completes the Golden Thread
  • Legal and ethical considerations of a discharge summary
  • When to write the discharge summary
  • The role of the termination letter

• The Intake Summary
  • Administrative, legal, and clinical requirements
  • How the intake summary initiates the golden thread and lays the groundwork for justifying medical necessity.
  • Establishing the connection between the diagnosis and treatment
  • What to include in a trauma informed intake
  • Deadline for writing the intake summary

MODULE 6: 37 TRIGGERS TO AUDITS, CLAW BACKS, AND ETHICAL ISSUES AND HOW TO AVOID THEM (45 minutes)

• What triggers an audit
• How to fail an audit
• Honest mistakes that can be seen as insurance fraud
• Ethical challenges in documentation and how to handle them
• The role of Informed Consents in clinical documentation
• Basic Do’s and Don’ts
• Paper notes or EHR?
• What’s next
  • Avoiding documentation fatigue and making yourself crazy
  • To catch up or move on?
  • Assessing your needs
  • Making your plan
  • Additional resources