What’s Missing From Your Charts: Writing Great Progress Notes
Online Course Materials: Articles Audios Articles Videos
Developed by Barbara Griswold, LMFT
Tokens may NOT be used with this course.
General Course Description
While you may shiver at the idea of an insurance plan, ethics committee, or licensing board reviewing your psychotherapy charts, this is happening more frequently — even to therapists who don’t work with insurance. In these cases, well-written records are essential, can be your only defense, and can assist clients in getting treatment or disability approval.
But if you are like most therapists, you never received training in how to write notes. And you may not realize how your current note-keeping habits can hurt you – and your clients. For example, did you know that keeping poor notes may be considered fraud or unprofessional conduct, or lead insurance plans to ask for money back?
This intermediate course consists of a video recording of a Webinar (audio and text versions available also) and will teach you how to write brief notes that satisfy legal, ethical, and insurance expectations, so that you’ll feel confident if you receive a records request. You’ll be introduced to 3 note templates. Sample progress notes are analyzed with examples of what “good” progress notes look and sound like.
Other topics will include:
- Telehealth documentation requirements
- What insurance plans and licensing boards require in notes
- What is required in intake documentation
- Documenting “medical necessity,” the key to insurance coverage and treatment approvals
- Why your notes may be requested — and how to deal with this
- This course will teach the participant to
- Identify how writing vague progress notes can be harmful, both to therapists and clients.
- Identify common insurance plan – and licensing board – documentation requirements.
- Identify how to document “medical necessity,” the criteria used by health plans to approve ongoing treatment.
- Why Don’t Therapists Keep Better Notes? Results of a Survey
- Why Therapists Should Keep Better Notes
- It’s Not Just Required by Insurance Plans
- How it Can Assist Therapists in Providing Higher Quality Care
- How it Can Assist Clients Applying for Disability or More Sessions with Insurance
- What Insurance Plans Require in Initial Evaluations
- What Insurance Plans Require in Progress Notes
- Understanding the Key to Treatment Approvals: Documenting Medical Necessity
- Why There Has Been an Increase in Chart Reviews
- Sample Progress Notes
- “Can This Progress Note Be Saved?”
- SOAP Notes Format
- DAP Notes Format
- Another Notes Format
- What to Do if You Fall Behind
- How To Save Time Writing Notes
- Reasons Charts Might be Requested