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Digital Seminar

Mastery in Mental Health Documentation & Medical Necessity: Comprehensive Clinical Documentation for Psychotherapists


Faculty:
Beth Rontal, LICSW
Duration:
5 Hours 48 Minutes
Format:
Audio and Video
Copyright:
Feb 22, 2018
Product Code:
WDS020727
Brochure Code:
CBDOCMED
Media Type:
Digital Seminar
Access:
Never expires.

  • Program no longer active
 Purchase Additional Participant CE »

Description

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.

Credits


Alcoholism and Drug Abuse Counselors

This course has been approved by , as a NAADAC Approved Education Provider, for 6 continuing education hour(s). NAADAC Provider #77600, is responsible for all aspects of their programming. Content includes elements of one of the NAADAC 8 Counselor Skills Group. Full attendance is required to receive credit, variable credit for partial attendance may not be awarded based on the NAADAC guidelines.


Alcoholism and Drug Abuse Counselors - California

Provider approved by CCAPP-EI, Provider Number for 4.0 CEH(s).


Counselors - California

The State of California, Board of Behavioral Sciences will recognize and accept continuing education programs that are sponsored by providers approved by the American Psychological Association and the ASWB. Full attendance at this course will qualify for 4.0 hours of continuing education credit.


Counselors - Florida

is an approved provider with the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling Provider #50-466. This program is approved for 4.0 continuing education credit(s).


Counselors - Illinois

is a registered counselor continuing education sponsor approved through the State of Illinois Department of Professional Regulation (license # 197-000144). This program is offered for six (6) contact hour(s) of continuing education for counselors. Licensed counselors in other states should contact their individual state jurisdiction to review the current continuing education requirements for licensure renewal.


Counselors - National

This educational offering consists of 6 clock hour(s) of continuing education instruction. Credit requirements and approvals vary per state board regulations. Please save the course outline, the certificate of completion you receive from this offering and contact your state board or organization to determine specific filing requirements. 


Counselors - New York

Vyne Education, LLC., is recognized by the New York State Education Department’s State Board for Mental Health Practitioners as an approved provider of continuing education for licensed  mental health counselors #MHC-0027. This educational offering is acceptable for 4.0 continuing education hour(s). Full attendance is required to receive credit for Mental Health Counselors; variable credit for partial attendance may not be awarded based on the State Board guidelines.

 


Counselors - Ohio

is approved through the State of Ohio Counselor, Social Worker and Marriage and Family Therapist Board (provider #RCT091001). This program is offered for six (4.0) clock hour(s) of continuing education for counselors only. Licensed counselors in other states should contact their individual state jurisdiction to review the current continuing education requirements for licensure renewal.


Counselors - South Carolina

is an approved sponsor with the South Carolina Board of Examiners for LPC, AC and MFTs (Provider #104). This program is offered for 6 continuing education hour(s).


Counselors - Texas

is an approved sponsor of continuing education for licensed professional counselors through the Texas State Board of Examiners of Professional Counselors (Provider number 2709). This course is offered for 6 clock hour(s).


Marriage & Family Therapists - California

The State of California, Board of Behavioral Sciences will recognize and accept continuing education programs that are sponsored by providers approved by the American Psychological Association and the ASWB. Full attendance at this course will qualify for 4.0 hours of continuing education credit.


Marriage & Family Therapists - National

This educational offering consists of 4.0 clock hour(s) of continuing education instruction. Credit requirements and approvals vary per state board regulations. Please save the course outline, the certificate of completion you receive from this offering and contact your state board or organization to determine specific filing requirements.


Marriage and Family Therapists - Florida

is an approved provider with the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling Provider #50-466. This program is approved for 4.0 continuing education credit(s).


Marriage and Family Therapists - Illinois

is a registered marriage and family therapist continuing education sponsor approved through the State of Illinois Department of Professional Regulation (license # 168-000172). This program is offered for six (6) contact hour(s) of continuing education for marriage and family therapist. Licensed marriage and family therapist in other states should contact their individual state jurisdiction to review the current continuing education requirements for licensure renewal.


Marriage and Family Therapists - New York

Vyne Education, LLC., is recognized by the New York State Education Department’s State Board for Mental Health Practitioners as an approved provider of continuing education for licensed  marriage and family therapists #MFT-0020. This educational offering is acceptable for 6 continuing education hour(s). Full attendance is required to receive credit for Marriage and Family Therapists; variable credit for partial attendance may not be awarded based on the State Board guidelines.


Marriage and Family Therapists - Ohio

is approved through the State of Ohio Counselor, Social Worker and Marriage and Family Therapist Board (provider #RCT091001). This program is offered for six (6) clock hour(s) of continuing education for counselors and marriage family therapists. Licensed counselors and marriage and family therapists in other states should contact their individual state jurisdiction to review the current continuing education requirements for licensure renewal.


Marriage and Family Therapists - South Carolina

is an approved sponsor with the South Carolina Board of Examiners for LPC, AC and MFTs (Provider #104).  This program is offered for 6 continuing education hour(s).


Marriage and Family Therapists - Texas

is an approved sponsor of continuing education for licensed marriage and family therapists through the Texas State Board of Examiners of Marriage and Family Therapists (Provider number 195). This course is offered for 6 clock hour(s).


Other Professions

This educational offering qualifies for 4.0 continuing education hour(s) as required by many national, state and local licensing boards and professional organizations. Save your course outline and certificate of completion, and contact your own board or organization for specific filing requirements. 


Social Workers

is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB), through the Approved Continuing Education (ACE) program (an approved provider since 1999, approved period 1/27/2018-1/27/2021). maintains responsibility for the program. Social workers will receive 6 General Social Work Social Work continuing education clock hour(s) for participating in this course. Licensed social workers should contact their individual state jurisdiction to review the current continuing education requirements for licensure renewal. Visit ASWB's website at www.aswb.org for more information. This educational offering is at the Intermediate level for social workers.


Social Workers - California

The State of California, Board of Behavioral Sciences will recognize and accept continuing education programs that are sponsored by providers approved by the American Psychological Association and the ASWB. Full attendance at this course will qualify for 6 hours of continuing education credit.


Social Workers - Colorado

Vyne Education, LLC. is an approved provider with the Colorado Chapter of the National Association of Social Workers.  Provider #1712. This educational offering has been approved for 4.0 continuing education hours.


Social Workers - Florida

is an approved provider with the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling Provider #50-466. This program is approved for 4.0 continuing education credit(s).


Social Workers - New York

, SW CPE is recognized by the New York State Education Department’s State Board for Social Work as an approved provider of continuing education for licensed Social Workers #0043. This educational offering is acceptable for 4.0 continuing education hour(s). Full attendance is required to receive credit for Social Workers; variable credit for partial attendance may not be awarded based on the State Board guidelines.



Handouts

Faculty

Beth Rontal, LICSW Related seminars and products


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. 


Additional Info

Program Information

Access for Self-Study (Non-Interactive) Access never expires for this product.

Target Audience

Mental Health Administrators, Psychiatrists, Psychologists, Counselors, Alcoholism and Drug Abuse Counselors, Social Workers, Office Managers, Psychiatric Nurse Practitioners, Mental Health Nurses, Case Managers, Coding and Billing Personnel

Outline

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

HOW TO WRITE A SESSION NOTE

  • Definition of a Session Note and how it relates to the TX 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

INTAKE SUMMARY

  • Definition of an Intake Summary 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

COLLATERAL CASE NOTES

  • Definition of a Case/Collateral Contact Note and how it relates to the TX 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 TX Plan
  • Everything that’s needed in a Discharge Summary and why
  • How to write a Discharge Summary that completes the “golden thread” with examples

Objectives

  1. Describe the clinical documentation process from Intake to Discharge
  2. Determine how to use the behavioral language required by insurance companies
  3. Document what really happens in a session without violating HIPAA
  4. Justify medical necessity by employing the “golden thread”

Reviews

5
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1

Overall:      4.2

Total Reviews: 61

Comments

Hope E - ARDEN, North Carolina

"Thank you....this was great"

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