Misery or Mastery: Gold Standard Mental Health Documentation for Psychotherapists - Beth Rontal




On Demand


Instant Access! — Recorded on 25th March 2022

CPD & CE credits available: 6

TRAINING information

This is an on-demand training event. Watch anytime, anywhere at your convenience.

All course content related to this training will be accessible for 365 days after purchase.

Registration for this event will close on 24th March 2023


Clinical documentation has always been a professional standard of care. With the introduction of managed care and Medicare, the gold standard for documentation developed into the need to satisfy insurance company requirements. Record keeping changed from writing purely clinical records to including specific administrative information.

Note writing must now fulfill two distinct requirements. 1) Documentation must meet the administrative criteria to justify getting paid and 2) it must describe client or patient care in a way that justifies medical necessity. These requirements are what make up the official medical record. They have become so widely accepted, that even therapists who do not take insurance must meet these standards.

With minimal to no documentation training provided in graduate schools, there is little clarity about what or how much to write, and how to write it. In the quest to be thorough, clinicians often write long stories with unnecessary content. Or they write too little, afraid of providing confidential information. Or they leave out required clerical content that will result in a recoupment of payment. The result is disjointed information, wasted time, potential lost income, possible legal nightmares, a belief that documentation is a useless waste of time, and anxiety about the process.

Effective documentation should reflect on and contribute to good clinical care rather than be a diversion.

In this workshop, you will learn the gold standard of clerical and clinical requirements that belong in your medical record. You will learn to apply a formula for translating your professional skills and intuition into insurance friendly and clinically relevant documentation from intake to discharge. This includes the Diagnostic Summary, Treatment Plan, Progress Note, Case/Collateral Notes, and Discharge Summary. You will also learn over 25 red flags that can trigger an audit, incur a recoupment, or create legal problems — and how to avoid them. This course is highly interactive and even fun. Learn the Gold Standard requirements of documentation for mental health professionals. Choose mastery over misery and breathe easier.

Learning Objectives

  • Demonstrate how to write clinical notes: Diagnostic Summary, Treatment Plan, Session Note, Case/Collateral Contact Note, & Discharge Summary with clarity and ease.
  • Demonstrate how to translate your work into the behavioural language required by insurance companies.
  • Apply the “golden thread” to create a clear connection from intake to discharge and between the problem, goals, objectives, and interventions so that medical necessity is justified.
  • Recognize how to protect the client and therapist with a thorough risk assessment.
  • Identify Red Flags that could trigger an audit and result in an insurance recoupment

About the Speaker

Beth Rontal, LICSW, the “Documentation Wizard,” is an internationally recognized and engaging speaker on mental health documentation for private practice clinicians. She mastered her teaching skills with thousands of hours supervising and training both interns and seasoned professionals while working at an agency for 11 years. She loves empowering clinicians to master the documentation process so they recognize how useful it can be clinical work. Her Documentation Wizard TM trainings and forms are used internationally.

Beth also writes blogs on clinical documentation, co-chairs the NASW Private Practice Shared Interest Group, and has an active private practice in Brookline, MA specializing in emotional eating and early mother loss. When not being a therapist, wife and mom, Beth also loves to sing and is developing her next cabaret.


CPD & CE credits available: 6

How do I receive these credits?

The participant must pass the multiple-choice test with a minimum score of 80%. There is a maximum of three attempts to achieve this.

The post-test is included in the price of the training.

Does my regulatory body accept the credits?

The CPD & CE credits awarded can be used towards your declaration to any governing regulatory body in your state or country, provided the content is relevant to your discipline.

Our trainings are accredited by:

– The CPD Group, London
– Canadian Counselling and Psychotherapy Association
– Australian Counselling Association

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Misery or Mastery: Gold Standard Mental Health Documentation for Psychotherapists - Beth Rontal

On Demand

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