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confidentiality

clinical documentation - progress notes - use name or client

October 25, 2024

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 Mental Health confidentiality,  progress notes,  style,  terminology

ai artificial intelligence chatGPT for writing therapy notes progress notes clinical mental health documentation - Documentation Wizard

March 25, 2024

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

Documenting Mental Health AI,  confidentiality,  progress notes,  review,  risks

Intake Summary - Beth Rontal, LICSW, Documentation Wizard - mental health psychotherapy documentation

March 1, 2024

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

Documenting Mental Health confidentiality,  EHR,  intake summary,  medical necessity

artificial intelligence AI for mental health clinical documentation

June 14, 2023

Can You Use AI for Mental Health Progress Notes?

Can You Use AI for Mental Health Progress Notes? Although AI has been around for quite a few years, it recently burst onto the scene like fireworks and is causing a lot of noise.  Some psychotherapists are already raving about how it cuts down on the time it takes to write their notes and … [Read more...] about Can You Use AI for Mental Health Progress Notes?

Documenting Mental Health AI,  confidentiality,  ethics,  progress notes

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