What’s Missing From Your Charts: Writing Great Progress Notes

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 (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