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