Mastery in Mental Health Documentation and Medical Necessity: Comprehensive Clinical Documentation for Psychotherapists – Beth Rontal

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Clinical documentation is a professional standard of care, but there is little guidance about what to write or how to write it. Paperwork can seem disconnected from helping clients. It can create confusion and anxiety about possible violations of privacy and confidentiality, potentially traumatic audits, and even legal nightmares.

What are the criteria for a client needing services? How is medical necessity justified? How can the “golden thread” of documentation be created and maintained so that audits are passed and a professional standard of care is maintained even when insurance is not involved?

This recording can help answer these questions and more! Effective clinical documentation is not rocket science. It is a formula that, once learned, translates clinical thinking into clean documentation, so that writing notes and treatment plans can be done quickly and efficiently, getting authorizations is easy, and audits are not as threatening. In addition, confidentiality is not violated and continuity of care is practiced.

Choose mastery over misery and allow good clinical documentation to be a contribution to high quality clinical work rather than a detour away from it.

1. Explain the importance of proper documentation in informing clinical decision-making.
2. Evaluate the role of the clinical diagnosis in justifying medical necessity and providing more effective services to clients.
3. Determine how to use the behavioral language required by insurance companies to facilitate delivery of services to clients.
4. Explain how to document what really happens in a clinical session without violating privacy or confidentiality.
5. Assess medical necessity by employing the “golden thread” for improved treatment outcomes.
6. Identify potential red flags in documentation and the proper corrective measures for them

Why is Documentation the Topic Clinicians Love to Hate?

• How do you feel about documentation?
• Why is documentation so daunting?
• Why is documentation the topic clinicians love to hate?
• Why document?

Medical Necessity

• Definition of Medical Necessity
• What is “The Golden Thread” and how does it relate to medical necessity?
• What is the role of the diagnosis in justifying medical necessity?

How to Write a Treatment Plan

• Definition of a treatment plan
• Everything that’s needed in a treatment plan and why
• How to write a treatment plan that justifies medical necessity using behavioral language and the “golden thread” with examples
• Practice writing a treatment plan

How to Write a Session Note

• Definition of a session note and how it relates to the treatment plan
• Everything that’s needed in a session note and why
• How to write a session note that justifies medical necessity using behavioral language and the “golden thread” with examples
• Practice writing a session note

How to Write an Intake Summary

• Definition of an intake summary and how it relates to all other documentation
• Everything that’s needed in an intake summary and why
• How to write an intake summary that lays the ground for medical necessity

How to Write Case/Collateral Contact Notes

• Definition of a case/collateral contact note and how it relates to the treatment plan
• Everything that’s needed in a case/collateral contact note and why
• How to write a case/collateral Contact Note that justifies medical necessity using behavioral language and the “golden thread” with examples

How to Write a Discharge Summary

• Definition of a discharge summary and how it relates to the treatment plan
• Everything that’s needed in a discharge summary and why
• How to write a discharge summary that completes the “golden thread” with examples