Documenting psychotherapy is done to summarize services provided to many audiences who have access including clients, payors, and potential legal situations that may occur. It is necessary for professional, legal, and ethical standards. Since psychotherapy is covered by medical insurance, the gold standard for documentation is now based on the need to satisfy insurance company requirements. The most rigorous standards for clinical documentation are Federal, which is why most third-party payors base their requirements on Medicare standards. That standard involves justifying the need for services conceptualized as “medical necessity.” A fundamental feature of medical necessity is part of a “Golden Thread.” When the Golden Thread is employed, each element of the therapeutic process is clearly documented so that the connection between all aspects of clinical work flows logically within each document and from one document to the other. The criteria for a client needing services and the Golden Thread work together to justify medical necessity. Best practice documentation includes the clinician’s voice in a succinct narrative that makes clear how they conceptualize the treatment while also utilizing templates to facilitate ease of documenting what is needed.
Good documentation helps organize clinical thinking. Progress notes, treatment plans, case and collateral contact notes, discharge and diagnostic summaries can be done quickly and efficiently. Documentation can provide a vehicle for formulating and reflecting on high quality clinical work rather than being a detour or afterthought. Good documentation supports good clinical practice, facilitates getting authorizations, and helps mental health professionals and clinics pass insurance audits. When practitioners are skilled at documenting, there is a reduction in work related anxiety, increased productivity, and increased job satisfaction. Beth will simplify clinical documentation by teaching her effective, efficient, and distinct procedure, which result in medical records that are clear, compliant, and clinically useful.
Through lecture, group discussion, case examples, practice, and Q & A, you will learn the “formula” to translate your clinical intuition into language required for medical record writing. Based on a videotaped demonstration interview of a client session, you will practice composing the two main documents therapists write most often: the treatment plan and progress note.
You will be able to apply this process to whatever documentation system you use. The result is increased accuracy and efficiency, a reduction in anxiety and procrastination, and the satisfaction that your documentation will contribute to the high quality of care you provide. In addition to meeting standards of care, you will notice a reduction in time spent writing paperwork.