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.