Paperwork Crash Course

Consult Monday

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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.

Too Much Notation VS Too Little:

• 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.

Clinical Relevance:

• Document information if it’s relevant to their reason for the visit.
• Think about your phrasing: is it respectful and nonjudgmental? Is it empathetic?

Check out Maelisa's FREE Private Practice Paperwork Crash Course

Maelisa Hall of QA Prep

Maelisa Hall is a licensed psychologist whose passion is to help therapists create rock solid documentation so they can spend more time with their clients and less time worrying about paperwork. She consults with psychotherapists in private practice, agencies and group practices to teach them things like how to write great notes, what to consider if insurance is involved, how to document high risk issues and what forms they actually need for their clientele. You can find her at qaprep.com

What I Wish I'd Said Wednesday

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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.

Check out Maelisa's FREE Private Practice Paperwork Crash Course

Follow Through Friday

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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.

Check out Maelisa's FREE Private Practice Paperwork Crash Course

Allison Puryear, LCSW, CEDS of Abundance Practice-Building

Allison Puryear is an LCSW with a nearly diagnosable obsession with business development. She has started practices in three different cities and wants you to know that building a private practice is shockingly doable when you have a plan and support. You can download a free private practice checklist to make sure you have your ducks in a row, get weekly private practice tips, and join the Abundance Practice-Building Group to gain the confidence and tools you need to succeed.