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Digital Seminar

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


Faculty:
Beth Rontal, MSW, LICSW
Duration:
6 Hours 51 Minutes
Copyright:
28 Feb, 2025
Product Code:
POS055315
Media Type:
Digital Seminar
Access:
Never expires.


Description

“I love paperwork!”

--Said NO clinician, EVER.

Yet, the success of your practice depends on your ability to write good intake summaries, treatment plans, session notes, case/collateral notes, and discharge summaries. Taken together, these pieces to the documentation puzzle support your goal of providing quality services to your clients. They also impact the stability and success of your practice. When done well, they result in piece of mind and timely payment from insurance companies. When done poorly, they lead to the misery of denials, audits, and lost income.

The great news is that you CAN become proficient at mental health documentation and medical necessity. This seminar provides clear and simple guidelines for recordkeeping that adheres to professional standards and ethical codes, supports delivery of quality care, and reduces errors and delays in payments.

You will receive expert instruction from Beth Rontal, MSW, LICSW, affectionally known as the Documentation Wizard. For over 15 years, Beth has been instrumental at changing how individuals and organisations approach documentation. The results speak for themselves. Rates at which paperwork was returned to clinicians for correction have dropped significantly, in one case from 65% to under 8%. This gave clinicians back 3 to 5 clinical hours per week, saving thousands of dollars and improving job satisfaction.

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.



CPD

PESI Australia, in collaboration with PESI in the USA, offers quality online continuing professional development events from the leaders in the field at a standard recognized by professional associations including psychology, social work, occupational therapy, alcohol and drug professionals, counselling and psychotherapy. On completion of the training, a Professional Development Certificate is issued after the individual has answered and submitted a quiz and course evaluation. This program is worth 7 hours CPD for points calculation by your association.



Handouts

Faculty

Beth Rontal, MSW, LICSW's Profile

Beth Rontal, MSW, LICSW Related seminars and products


Beth Rontal, LICSW, also known as the Documentation Wizard, spent 20 years as a theater costume designer before bringing her eye for structure and creativity to clinical work. Over 24 years as a trauma therapist, she discovered an unexpected passion: transforming the documentation clinician’s dread into a powerful clinical tool.

While supervising at a community mental health agency for 11 years, Beth developed a practical formula for treatment plans and progress notes that transformed her supervisees’ experience of note writing. In 2012, she founded Documentation Wizard® to help therapists turn clinical intuition into simplified, effective documentation. Her trainings and comprehensive forms – reviewed by attorneys and a bioethicist – and her work developing an electronic documentation system have empowered clinicians worldwide. Today, Beth has a private practice in Boston, MA specializing in emotional eating and is an internationally recognized speaker and consultant on mental health documentation.


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.


Additional Info

Access for Self-Study (Non-Interactive)

Access never expires for this product.

For a more detailed outline that includes times or durations of time, if needed, please contact cepesi@pesi.com.


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. Analyse 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
    • Operationalise 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

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