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mental health clinical documentation - intake note and diagnostic session note - Documentation Wizard

May 9, 2023

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?

Session Notes clinical documentation,  clinical documentation specialist,  counseling,  diagnostic session note,  psychotherapist,  psychotherapy,  therapist,  therapy

should I document medications on progress notes - Documentation Wizard

April 20, 2023

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?

Clinical Documentation,  Progress Notes,  Session Notes clinical documentation,  clinical documentation specialist,  counseling,  medications,  mental health care,  mental health documentation,  progress notes,  psychotherapist,  psychotherapy,  therapist,  therapy

how to document prognosis for mental health

July 13, 2021

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

Session Notes audit,  clinical documentation,  clinical documentation specialist,  counseling,  diagnosis,  health insurance audit,  medicare,  mental health,  mental health care,  mental health therapist,  prognosis,  psychotherapist,  psychotherapy,  therapist,  therapy

how to survive a health insurance audit for psychotherapists

May 7, 2021

How To Survive A Health Insurance Audit

The Insurance Vultures are Circling Insurance companies have recently been conducting audits, like vultures looking for dinner. Especially Medicare. Fight, flight, freeze, or fawn! An audit letter from a health insurance company is enough to send shock waves through your body and make your … [Read more...] about How To Survive A Health Insurance Audit

Session Notes audit,  counseling,  health insurance,  health insurance audit,  medicare,  psychotherapist,  psychotherapy,  psychotherapy notes,  therapist,  therapy

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Recent Articles

  • Can You Combine the Intake Summary and the Diagnostic Session Note?
  • Should I Document Medications on Progress Notes?
  • Mental Health Documentation for Workman’s Compensation

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