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Clinical Documentation: What You Need and What You Don't, Ep. 02

Light Up The Couch

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Is It a Bad Idea for a Client to Stop Treatment?

In terms of medical necessity in this particular session, you may be thinking, well, there really isn't any medical necessity because she's really happy. So let's assume that you think it is a bad idea for her to stop treatment. This justification, your clinical reasoning becomes part of your medical necessity for this particular client. Make sure that you're documenting that that you're feeling. That's the part that is your clinical interpretation of this client's care and their presentation.

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