FLASH SALE on Updated Diagnostic Assessment Toolkit thru 9/2 Learn More

Documentation Wizard, LLC

Documenting Medical Necessity for Psychotherapists

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?

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