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Documenting Medical Necessity for Psychotherapists

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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?

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

clinical mental health documentation workman's comp

March 23, 2023

Mental Health Documentation for Workman’s Compensation

Mental Health Documentation for Workman’s Compensation A therapist recently asked me how to document for a Workman’s Compensation claim.  Some companies will accept a summary of treatment.  Most will want the client’s full record.  That will include the Diagnostic Assessment, … [Read more...] about Mental Health Documentation for Workman’s Compensation

Documenting Medical Necessity,  Progress Notes,  Psychotherapist Notes clinical documentation,  clinical documentation specialist,  mental health documentation,  progress notes,  psychotherapist,  psychotherapy,  therapy,  workman's comp,  workman's compensation

Documentation Wizard mental health clinical documentation expert

February 15, 2023

5 Types of Insurance Reviews

If you’ve ever gotten a letter from a health insurance company and felt your blood pressure spike while you open it, you’re not alone. The fear of being audited can cause as much anxiety as having a suicidal client.  But just like a range in client risk, there is more or less risk involved with … [Read more...] about 5 Types of Insurance Reviews

Clinical Documentation,  Psychotherapist Notes audit,  audits,  clinical documentation,  clinical documentation specialist,  progress notes,  psychotherapist,  psychotherapy,  therapist,  therapy

different forms for documentation as viewed by a therapist

December 30, 2022

What Makes Documentation Wizard® Forms Different? (From All Other Forms)

Remember being a teenager at a high school dance?  You wanted to cut the rug, but you didn’t know how because you were never taught.  If you intuitively knew how to “just dance,” you were golden. Otherwise, you may have either flailed around imitating your friends, or hid in the corner … [Read more...] about What Makes Documentation Wizard® Forms Different? (From All Other Forms)

Clinical Documentation clinical documentation,  clinical documentation specialist,  progress notes,  psychotherapist,  psychotherapy

Taking Progress Notes

September 18, 2021

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

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 … [Read more...] about I’d Rather Clean the Toilet than Write Progress Notes: Making Peace With An Essential Task

Documenting Medical Necessity audits,  clinical documentation,  clinical documentation specialist,  progress notes,  psychotherapist

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”

Clinical Documentation,  Documenting Medical Necessity,  Passing Audits,  Psychotherapist Notes audits,  golden thread,  progress notes

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. Even if you do not take insurance, if you see a client who has out-of-network benefits and uses a PPO, you can still be audited. This means you still have to justify medical … [Read more...] about I Don’t Take Insurance. Do I Still Need to Write Treatment Plans and Progress Notes?

Documenting Medical Necessity,  Private Pay,  Progress Notes,  Psychotherapist Notes,  Session Notes,  Treatment Plans progress notes,  treatment plans

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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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