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?
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 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