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medical necessity

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 am fond … [Read more...] about Client, Patient, or Name: Which to Use in Mental Health Documentation?

Clinical Documentation,  Documenting Medical Necessity,  Psychotherapist Notes clinical documentation,  clinical documentation specialist,  counseling,  medical necessity,  progress notes,  psychotherapist,  psychotherapy,  therapist,  therapy

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?QUESTIONI'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 progress … [Read more...] about Question & Answer: Intake Summary

Documenting Medical Necessity clinical documentation,  clinical documentation specialist,  counseling,  intake summary,  medical necessity,  psychotherapist,  psychotherapy,  therapist,  therapy

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