Essential Documentation Training
Original price was: $297.00.$252.45Current price is: $252.45.
Misery or Mastery®
Essential Documentation for Psychotherapists
… empowering mental health professionals to translate their clinical intuition into effective documentation
There Be a DSM Code for “Documentation Anxiety”!
If you’d rather clean the toilet than write your progress notes, you’re not alone.
Mental health documentation is the subject almost every therapist loves to hate. For a good reason. It wasn’t taught in grad schools, and it’s rarely taught on the job.
Do you:
- Lose sleep worrying about audits or legal involvement?
- Spend too much time writing notes, procrastinate or avoid them?
- Wonder if you’re writing too little or too much?
- Feel unsure about regulatory standards?
- Worry about how to preserve client confidentiality?
- Think writing notes is a clinically irrelevant waste of time?
Every therapist knows that avoiding progress notes puts their practice in jeopardy.
You may never learn to love writing your notes but if you choose mastery over misery, your good clinical documentation will not only be meaningful, it will contribute to and reflect high quality care – and protect your income at the same time.
What is included in this training
A series of 6 videos to which you have unlimited online access for one year.
The series comes with:
- Workshop Manual / Powerpoint slide deck to make comments and use as reference while writing your notes.
- Recording of each video to listen in the car, at the gym, or even while washing the dishes.
- Practice treatment and practice progress note forms to be used during the video training.
- Complete agenda detailing entire workshop.
COST: $297 $252.45
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Add TRAINING CEs to your Essential Documentation Training ( learn more )
$30
What You’ll Learn
- Recognize obstacles to writing clear and concise documentation
- Translate clinical skill and intuition into the language required by insurance companies
- Apply the Golden Thread to justify medical necessity from intake to discharge.
- Document what really happens in a therapy session without violating confidentiality
- Analyze clinical, legal, and ethical red flags of documentation and how to avoid them
Video Schedule
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
$297 $252.45
what others are saying
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
Become a Documentation Wizard
Essential Documentation Training
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$297 $252.45
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