Instructor: Beth Rontal, LICSW
Location: Waltham MA or on live zoom video conference, depending on COVID-19 restrictions
Clinical Documentation has always been integral to the professional standard of care. Yet many psychotherapists are unsure how to document the good work they provide. As a result, they can feel at the mercy of insurance companies, spending an enormous amount of time justifying treatment, fighting rejected insurance claims, fearing or preparing for audits, writing disability reports and losing income. Clinicians both in private practice and those working in agencies and group practices, as well as clinic owners and managers report there is little guidance about what to write while clinicians find that there is little time to write it. Paperwork often seems unrelated to being helpful to the client. Confusion over third-party expectations and often substandard paperwork is a common result, leaving both clinician and clinic vulnerable to a financial loss if records are audited, or to legal, ethical or professional issues if records are subpoenaed.
Concerns about addiction, child safety, family violence, legal issues, and the corresponding rise in oversight, whether from insurance companies, social service departments, workman’s compensation, or the courts, necessitate nuanced, high quality keeping. Because the courts can mandate access to records, understanding issues of confidentiality and privacy in relationship to documentation requirements are critical.
Good documentation should help organize clinical thinking. Progress notes, treatment plans, case and collateral contact notes, discharge and diagnostic summaries can be done quickly and efficiently and provide a vehicle for formulating and reflecting on high quality clinical work rather than being a detour or afterthought. Good documentation supports good clinical practice, facilitates getting authorizations, and helps mental health professionals and clinics pass insurance audits, thus saving money in potential recoupments and lost productivity. When practitioners are skilled at documenting their work there is a reduction in work related anxiety and increased job satisfaction.
Meeting The Standards
Since psychotherapy is covered by medical insurance, the gold standard for documentation is now based on the need to satisfy insurance company requirements. The most rigorous standards for clinical documentation are Federal, which is why most third-party payors base their requirements on Medicare standards.
That standard is conceptualized as “medical necessity.” A fundamental feature of medical necessity is, the “Golden Thread.” When the Golden Thread is employed, each element of the therapeutic process is clearly documented so that the connection between all aspects of clinical work flows logically from one document to the other. In-other-words, the criteria for a client needing services and the Golden Thread work together to justify medical necessity. At the same time, it is important that the clinician’s voice be heard in a narrative so that it is clear how they conceptualize the treatment rather than relying solely on a template with boiler plate drop down menus. When clinical documentation is operationalized using this effective, efficient, and distinct procedure, medical records are clear, compliant and clinically useful. Documentation is necessary even for those psychotherapists who do not take insurance but still wish to meet professional, legal and ethical standards.
Through lecture, group discussion, case examples, and lots of questions and answers, you will learn the “formula” to translate your clinical intuition into the behavioral language required for a diagnostic assessment, treatment plan, progress note, case/collateral contact note and discharge summary so that you pass an audit and avoid legal nightmares. Based on a videotaped interview between a client and therapist, you will practice composing the two main documents therapist write most often: the treatment plan and progress note.
You will be able to apply this process to whatever documentation system you use. The result is increased accuracy and efficiency, a reduction in anxiety and procrastination, and the satisfaction that your documentation will contribute to the high quality of care you provide. In addition to meeting standards of care, you will notice a reduction in time spent writing paperwork that can lead to greater job satisfaction and less burnout.
Comments from people who have taken the Misery or Mastery workshop with Beth
The class is improving my clinical work as well as my documentation skill. -- Barbara Kaplan, LICSW
Why documentation is the topic every clinician loves to hate.
Why we document and how the process became bound to insurance company standards.
Writing for different “masters.”
Documentation as a contribution to good clinical work.
The “golden thread” and how it relates to medical necessity.
Anxiety reducing answers to common questions.
How to avoid documentation fatigue.
9:30 am to 10:30 am - The Treatment Plan
All the elements necessary in a treatment plan and why
The treatment plan “formula” that implements that Golden Thread and justifies medical necessity
How and why to operationalize the presenting problem using behavioral language required by insurance companies with case example
Creating a clear connection between the problem, goals, objectives, interventions, and progress
Protecting client and therapist with a risk assessment
10:45 am to 11:45 pm- Continuation of the Treatment Plan
Evaluating and documenting progress
Frequency of treatment plans
How to avoid making yourself crazy writing your treatment plans
Watching a videotaped session and practice writing a treatment plan
11:45 to 12:30 PM- The Session Note
All the elements necessary in a session note and why
Writing a session note that justifies medical necessity using behavioral language and the “golden thread” with case examples
Maintaining client confidentiality
Justifying multiple sessions
How to document changes in treatment using the session note
Practice writing a session note
1:30 to 2:15 pm- The Case/Collateral Contact Note
The difference between a Case and Collateral Contact Note
Everything that’s needed in a Case and Collateral Contact Note and why
Relationship to the treatment plan
How to write a case/collateral Contact Note that maintains the “golden thread” and justifies medical necessity with case examples
Clinical and legal Importance of Case/Collateral Contact Note
2:15 to 3 PM- The Discharge Summary
Definition of a discharge summary and how it relates to the treatment plan
Everything that’s needed in a discharge summary and why
How the discharge summary completes the Golden Thread
Legal considerations of a discharge summary
To send a termination letter or not
3:15 to 3:45 PM- The Diagnostic Assessment
How to write a diagnostic summary that lays the ground for writing a treatment plan and initiates the Golden Thread
Establishing the connection between the diagnosis and treatment
What’s needed in a diagnostic summary and why
Legal requirements of a diagnostic summary
When to write a diagnostic summary
3:45 PM to 4:15 PM- Red Flags
What triggers an audit
How to fail an audit
Examples of documentation mistakes that can be interpreted as insurance fraud
4:15 to 4:30 PM- To EHR or not?
What is an electronic health record?
Are paper notes OK?
4:30 – 4:45 PM
Complete course evaluations
- Participants will identify several specific details of a clinical documentation process for writing successful treatment plans, session notes, case/collateral contact notes, discharge and diagnostic summaries.
- Participants will demonstrate how to translate their work into behavioral language required by insurance companies
- Participants will define the “golden thread” to justify medical necessity.
- Participants will identify red flags and that could trigger an audit, incur an insurance recoupment, and lead to legal problems.
- Participants will articulate a minimum of three pros and cons of using paper notes vs. an electronic medical record.
Beth’s training empowers clinicians, reduces anxiety about documentation, and furthers professional integrity. It simplifies the documentation process by systematically linking effective documentation to quality care. This helps to pass audits and protect income. Beth writes blogs on clinical documentation, co-chairs the NASW Private Practice Shared Interest Group, and has a private practice in Brookline, MA specializing in working with people who struggle with emotional eating. She is a Certified Professional in Tapas Acupressure Technique®, has Level II training in Internal Family Systems and is a member of New England Society for the Treatment of Trauma and Dissociation.
Individual registration is $140.00, $130 early registration for individuals, $125 groups of two or more, $115 early registration for groups. Early registration ends on May 1, 2020. You must pay together by check in the same envelope or with the same credit card or Paypal account to qualify for group registration.
First Parish Church 50 Church Street Waltham MA 02452
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