Paperwork Crash Course

Consult Monday
[et_pb_divider color="#000000" show_divider="on" divider_style="solid" divider_position="top" hide_on_mobile="on" /]For Consult Monday, we discuss:
- How to follow the rules without spending all day on notes
- Pick the central theme for the session and focus on that but include anything that feels clinically relevant.
- New clinicians usually get OTJ training regarding clinical documentation. Some agencies may want a lot, some agencies may want bare-bones style notes. When documenting, keep in mind the best interest of your clients if there are any lifestyle issues or specific life events that may come up again in therapy.
- Document information if it’s relevant to their reason for the visit.
- Think about your phrasing: is it respectful and nonjudgmental? Is it empathetic?
Maelisa Hall of QA Prep

What I Wish I'd Said Wednesday
[et_pb_divider color="#000000" show_divider="on" divider_style="solid" divider_position="top" hide_on_mobile="on" /]For What I Wish I'd Said Wednesday we discuss:
Notation For Insurance Purposes:
- For bill-directly or super-bill clinicans: Insurances can ask questions about therapy. This makes a statment of progress in your notes necassary as well as the continued need for therapy. Establish that therapy is BOTH needed and working.
- Insurance doesn’t pay for personal development type of therapy and that is the clinician’s responsibliity. Make sure your clients meet the criteria to their diagnosis and that the progress they’re having relates to their diagnosis.
- Make sure your cross your Administrative Ts and Dot those Is:
- Have your CPT codes down and acruate and include your start and stop times even if EHR records it for you.
Follow Through Friday
[et_pb_divider color="#000000" show_divider="on" divider_style="solid" divider_position="top" hide_on_mobile="on" /]For Follow Through Friday we discuss:
How to Catch Up if You’re Behind:
- Getting behind is common.
- Create a regular schedule for your notes before you create a catch-up plan.
- Are you relying on the crutch notebook?
-
Your catch up plan: # of notes x15 minutes per note.
- Spread it out over time or do a big chunk.
- Catch up per client, it’s easier to remember.
- If you don’t remember, don’t make it up!
- There are benefits to having a cumulative chart on your client so consecutive and clear documentation is key.
Allison Puryear, LCSW, CEDS of Abundance Practice-Building

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