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Documenting Medical Necessity for Psychotherapists

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progress notes

Trees rooted in the storm as an example of staying grounded as a therapist

September 18, 2025

When You’re Just as Triggered as Your Client: Staying Grounded in a Polarized World

How do we help clients process traumatic events when we're struggling to process them ourselves? Another tragedy. Another polarizing event that sends shock waves through our communities and straight into our therapy offices. Whether it's a mass shooting, a terrorist attack, or political violence, … [Read more...] about When You’re Just as Triggered as Your Client: Staying Grounded in a Polarized World

Clinical Documentation,  Session Notes boundaries,  documentation,  ethics,  mindset,  productivity,  progress notes,  psychotherapist,  therapist overwhelm,  time management

In an uncertain world, Therapist protecting her client's privacy

March 15, 2025

Mental Health Documentation in an Uncertain World

Ethical Considerations for Psychotherapists In today’s rapidly shifting social and political landscape, therapists are navigating new challenges when it comes to documentation. Many clinicians find themselves balancing truthful and ethical documentation with the increased need to protect client … [Read more...] about Mental Health Documentation in an Uncertain World

Documenting Mental Health diagnosis,  ethics,  medicare,  passing audits,  progress notes,  psychotherapist,  psychotherapist notes

Documentation Wizard - Documenting Medical Necessity for Psychotherapists - dirty dishes and progress notes

November 12, 2024

What do Progress Notes and Dirty Dishes Have in Common?

What do Progress Notes and Dirty Dishes Have in Common? If you don’t write your notes or do your dishes, you can go hungry. Let’s face it, no one likes washing dishes or writing progress notes. They can both pile up faster than rabbits reproduce. But everyone likes it when they’re done. If the … [Read more...] about What do Progress Notes and Dirty Dishes Have in Common?

Documenting Mental Health mindset,  productivity,  progress notes,  time management

Documentation Wizard body-doubling co-working sessions to get therapy progress notes done

November 4, 2024

BODY-DOUBLING: Why it Helps Psychotherapists Get Progress Notes DONE!

Why Body-Doubling Helps Psychotherapists Get Progress Notes DONE! “Exhausting, annoying, demoralizing, and lonely.” This is a common refrain I hear from psychotherapists about documentation. These normal feelings breed avoidance, which leads to falling behind on notes. Behind long enough, it’s … [Read more...] about BODY-DOUBLING: Why it Helps Psychotherapists Get Progress Notes DONE!

Private Practice Therapy accountability,  body-doubling,  productivity,  progress notes

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

selfcare calm seas with black rocks lined up

August 8, 2024

Mental Health Documentation and Selfcare

Why in the world would anybody put “selfcare” and “documentation” in the same sentence? Because when therapists start feeling overwhelmed and burnt out the very first thing that’s sacrificed are progress notes! Then the inner Critic berates you by saying, “you’re a bad therapist because you’re … [Read more...] about Mental Health Documentation and Selfcare

Private Practice Therapy burnout,  progress notes,  self-care,  workflow

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

Timely Progress Note Completion

July 6, 2023

Timely Progress Note Completion in Mental Health Documentation

The most frequently asked question I get in my documentation course is, “What is the deadline for progress note completion?  This is a frustrating question because like so many aspects of mental health, there is no definitive answer. Understanding the Confusion Our professional codes of … [Read more...] about Timely Progress Note Completion in Mental Health Documentation

Documenting Mental Health billing,  ethics,  medical necessity,  progress notes,  timely documentation

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

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?

Documenting Mental Health compliance,  coordination of care,  medications,  progress notes

Taking Progress Notes

September 18, 2021

I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task

Q: I love being a therapist, but I hate writing progress notes and sometimes can’t bring myself to do it. I know it’s risky not to write them. Is there a way to make this task less onerous? A: Every therapist knows that avoiding progress notes puts their practice in jeopardy. But of the thousands … [Read more...] about I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task

Documenting Mental Health mindset,  procrastination,  productivity,  progress notes

writing psychotherapy notes

June 13, 2019

“I Love Writing Psychotherapy Notes”

If you ... experience doing your notes as a never-ending and tedious task, find it clinically irrelevant, andwould rather clean the bathroom I get it! You... don't know what or how much to write.resent the time it takes.wonder how to maintain client confidentiality.worry about legal … [Read more...] about “I Love Writing Psychotherapy Notes”

Documenting Mental Health best practices,  confidence,  progress notes,  workflow

documenting low self-esteemwith young women looking into a broken mirror

December 4, 2018

How to Document “Low Self-Esteem”

Esther Perel's definition of self-esteem is, "Seeing yourself as a flawed person, and still holding yourself in high regard." It's a common occurrence that clients come to treatment feeling broken and hopeless, reporting low self-esteem, and not believing they will ever be able to hold themselves in … [Read more...] about How to Document “Low Self-Esteem”

Documenting Mental Health assessment,  progress notes,  self-esteem,  treatment goals

Take insurance question

September 20, 2017

I Don’t Take Insurance. Do I Still Need to Write Treatment Plans and Progress Notes?

Yes!  Documentation has always been a standard in our profession so it's required.  And here are other good reasons why. These are the "negative" or the cover-your-butt reasons to maintain good documentation. Remember -- IF IT'S NOT DOCUMENTED IT DIDN'T HAPPEN. On the positive side, … [Read more...] about I Don’t Take Insurance. Do I Still Need to Write Treatment Plans and Progress Notes?

Private Practice Therapy private pay,  progress notes,  standards of care,  treatment plans

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