After twenty years of teaching clinical documentation, I've noticed something important: even the most well-intentioned clinicians can miss crucial cultural context in their mental status exams. This isn't about pointing fingers. We are always learning how to navigate our increasingly diverse client … [Read more...] about Why Your Mental Status Exam Needs a Cultural Lens (And How to Add One)
How to Document Prognosis for Mental Health
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
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”