The Gold Standard for Documentation
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, a possible HIPAA violation, the fuel for a traumatic audit, cause confusion about what to submit for a disability and workman’s compensation claim, and be a potential legal nightmare. 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?
This course 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.
Course Content
WHY IS DOCUMENTATION THE TOPIC CLINICIANS LOVE TO HATE?
MEDICAL NECESSITY
HOW TO WRITE A TREATMENT PLAN
HOW TO WRITE A SESSION NOTE
INTAKE SUMMARY
COLLATERAL CASE NOTES
HOW TO WRITE A DISCHARGE SUMMARY
| File type | File name | Number of pages | |
|---|---|---|---|
| Course Manual_Mastery in Mental Health Documentation & Medical Necessity: Comprehensive Clinical Documentation for Psychotherapists (1.42 MB) | Available after Purchase | ||
| Additional Handouts_Mastery in Mental Health Documentation & Medical Necessity (0.28 MB) | Available after Purchase |
Beth Rontal, LICSW, is a psychotherapist in private practice Brookline, Massachusetts, as well as a documentation consultant (wizard) and private supervisor. Ms. Rontal earned her MFA from Boston University, and her Master’s in Social Work from Simmons College in Boston. She was clinical supervisor at a mental health clinic for 16 years, where she was instrumental in developing and implementing the clinic’s first electronic documentation system. This implementation significantly reduced documentation time and errors and decreased the paperwork returned by clinicians from 65% to 8%, which in turn allowed for the addition of 3 to 5 clinical hours per week and generated thousands of dollars in savings for the company.
Ms. Rontal continues to be a developer and consultant in the field of Clinical Documentation. She is a sought-after national lecturer who has taught numerous seminars over the course of many years, in addition to having published numerous articles on the topic.
Please note: There will be a lunch and two 15-minute breaks; one in the morning and one in the afternoon. Lunch and break times will be announced by the speaker and at their discretion.
| 5 |
|
| 4 |
|
| 3 |
|
| 2 |
|
| 1 |
|
Satisfaction Guarantee
Your satisfaction is our goal and our guarantee. Concerns should be addressed to: PO Box 1000, Eau Claire, WI 54702-1000 or call 1-800-844-8260.
ADA Needs
We would be happy to accommodate your ADA needs; please call our Customer Service Department for more information at 1-800-844-8260.
Please wait ...