Mental Health Documentation & Medical Necessity: Simple, Clear Guidelines that Maintain Quality of Care and Protect Your Practice

CPD

Planning Committee Disclosure - No relevant relationships

All members of the PESI, Inc. planning committee have provided disclosures of financial relationships with ineligible organizations and any relevant non-financial relationships prior to planning content for this activity. None of the committee members had relevant financial relationships with ineligible companies or other potentially biasing relationships to disclose to learners.  For speaker disclosures, please see the faculty biography.

Handouts

Faculty

Beth Rontal, MSW, LICSW Related seminars and products

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Beth Rontal, MSW, LICSW, is a psychotherapist in private practice in 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 seminars over the course of many years, in addition to having published numerous articles on the topic. 

Speaker Disclosures:
Financial: Beth Rontal maintains a private practice. She is the founder and trainer for Documentation Wizard, LLC. Beth Rontal receives a speaking honorarium and recording royalties from Psychotherapy Networker and PESI, Inc. She has no relevant financial relationships with ineligible organizations.
Non-financial: Beth Rontal is a member of the NASW.

Objectives

1. Determine the importance of proper documentation in informing clinical decision-making.
2. Evaluate the role of the clinical diagnosis in justifying medical necessity and providing more effective services to clients.
3. Determine how to use the behavioural language required by insurance companies to facilitate delivery of services to clients.
4. Assess how to document what really happens in a clinical session without violating privacy or confidentiality.
5. Assess medical necessity by employing the “golden thread” for improved treatment outcomes.
6. Analyze potential red flags in documentation and the proper corrective measures for them.

Outline

Get Past Your Negative Feelings About Documentation 

• Documentation as a contributor to good clinical work
• Documentation through the lens of the “Golden Thread”
• Documentation as a protector of income and integrity
• Anxiety-reducing answers to common questions

Embrace the Requirement of Medical Necessity 

• The elements of medical necessity
• The “Golden Thread” as a key part of medical necessity
• Establish the connection between diagnosis and treatment

How to Write: 

• The Diagnostic Summary 
  • What’s needed in the diagnostic summary, and why
  • How the diagnostic summary initiates the path of the Golden Thread
• The Treatment Plan 
  • What’s needed in a treatment plan, and why
• Operationalize the presenting problem
  • • Questions to ask
  • Describe the diagnostic criteria in behavioural terms
  • Make a clear connection between goals, objectives, and interventions
  • Protect the client and the therapist with a thoughtful risk assessment
  • Evaluate client progress
  • How the treatment plan it continues the path of the Golden Thread
  • And more …
  • Activity: Write a treatment plan
• The Session Note 
  • The session’s note relationship to the treatment plan
  • What’s needed in a session note and why
  • Descriptive or narrative approach to interventions used
  • Changes to treatment plan
  • Justify multiple sessions
  • Activity: Write a session note
• The Case and Collateral Contact Note
  • What’s needed in a case and collateral contact note and why
  • Differences between case and collateral contact notes
  • Provide a clinical justification for the case/collateral consult
• The Discharge Summary 
  • What’s needed in a discharge summary, and why
  • How the discharge summary completes the Golden Thread

20 DOCUMENTATION RED FLAGS THAT LEAD TO TROUBLE

Target Audience

• Mental Health Administrators
• Marriage and Family Therapists
• Physicians
• Psychiatrists
• Psychologists
• Counsellors
• Social Workers
• Office Managers
• Mental Health Nurses
• Addiction Counsellors
• Nurses
• Other Mental Health Professionals