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 … [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 … [Read more...] about BODY-DOUBLING: Why it Helps Psychotherapists Get Progress Notes DONE!
Client, Patient, or Name: Which to Use in Mental Health Documentation?
Client, Patient, or Name: Which to Use in Mental Health Documentation? “What is the proper way to refer to a client when writing my notes? Do I use their first name, or do I refer to them as ‘client’ or ‘patient,’ which is their role in our relationship?” I get this question a lot and … [Read more...] about Client, Patient, or Name: Which to Use in Mental Health Documentation?
Documenting Group Therapy
To say that running groups is both challenging and rewarding is like saying that you love to cook but hate to clean up afterwards. The difference is that you can get others to clean up but you still need to write your own notes. REWARDS OF RUNNING GROUP THERAPY There’s truly something magical … [Read more...] about Documenting Group Therapy
Documenting Crisis Management – HELP!
From Chaos to Calm: Effective Crisis Intervention Strategies Naomi Golan, the creator of the Golan Model of Crisis Intervention (1978), describes a crisis as a person who faces a situation in which they feel so overwhelmed they go from a state of “balance to imbalance, and ultimately back … [Read more...] about Documenting Crisis Management – HELP!
Challenges with AI in Progress Notes
Insights into using AI from a Mental Health Therapist and Documentation Expert In 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
Question & Answer: Intake Summary
Question & Answer: How do I write an Intake Summary without violating client confidentiality? QUESTION I'm struggling with how to effectively document in a manner that satisfies "medical necessity" requirements while also protecting the privacy of my clients. I understand how to keep … [Read more...] about Question & Answer: Intake Summary
How to Opt-Out of Medicare and Still Get Paid
Your Guide to Opting Out of Medicare as a Mental Health Provider: and How Medicare Clients Can Get Reimbursed Yes, it is possible to see a Medicare client, get your full fee, and for the client to not have to pay for your service. The process isn’t even that difficult. Unlike most things … [Read more...] about How to Opt-Out of Medicare and Still Get Paid
The Ethics of Other People Writing Your Treatment Plan
The Ethics of Other People Writing Your Treatment Plan QUESTION Is it ethical for one therapist to write a Treatment Plan for another therapist to use? At my group practice, I’m often asked as a licensed therapist to do an Intake and write the Treatment Plan to hand off to a master’s … [Read more...] about The Ethics of Other People Writing Your Treatment Plan
Can You Combine the Intake Summary and the Diagnostic Session Note?
QUESTION: Can You Combine the Intake Summary and the Diagnostic Session Note? My EHR combines the Intake Summary and the Diagnostic Session Note and calls it the Intake Session Note. What do you think of combining them? ANSWER I prefer the documents to be separated, but there is no … [Read more...] about Can You Combine the Intake Summary and the Diagnostic Session Note?
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, … [Read more...] about Should I Document Medications on Progress Notes?
Mental Health Documentation for Worker’s Compensation
Mental Health Documentation for Worker’s Compensation A 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 … [Read more...] about Mental Health Documentation for Worker’s Compensation
5 Types of Insurance Reviews
If you’ve ever gotten a letter from a health insurance company and felt your blood pressure spike while you open it, you’re not alone. The fear of being audited can cause as much anxiety as having a suicidal client. But just like a range in client risk, there is more or less risk involved with … [Read more...] about 5 Types of Insurance Reviews
Winning an Insurance Audit Appeal!
I WON an Overpayment Recoupment for mental health services from Blue Cross Blue Shield! And I’m sharing what I did in case you find yourself dealing with the same thing. I got the dreaded insurance recoupment letter from BCBS saying they overpaid me (over $1700) and demanded their money back. … [Read more...] about Winning an Insurance Audit Appeal!
What Makes Documentation Wizard Forms Different? (From All Other Forms)
Remember being a teenager at a high school dance? You wanted to cut the rug, but you didn’t know how because you were never taught. If you intuitively knew how to “just dance,” you were golden. Otherwise, you may have either flailed around imitating your friends, or hid in the corner … [Read more...] about What Makes Documentation Wizard Forms Different? (From All Other Forms)
Should I Use a Treatment Planning Book?
Should I Use a Treatment Planning Book? Like many answers to questions about mental health, the answer to this common question on whether or not you should use a treatment planning book is a bit more complicated than a simple yes or no. When discussing treatment plans during my trainings, … [Read more...] about Should I Use a Treatment Planning Book?
I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task
Q: I love being a therapist, but I hate writing progress notes and sometimes can’t bring myself to do it. I know it’s risky not to write them. Is there a way to make this task less onerous? A: Every therapist knows that avoiding progress notes puts their practice in jeopardy. But of the thousands … [Read more...] about I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task
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