Misery or Mastery: Gold Standard Mental Health Documentation for Psychotherapists – Beth Rontal
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. Read More
TRAINING information
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. Read More
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 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
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
