Clinical Documentation: What You Need and What You Don't, Ep. 02
Light Up The Couch
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The Concept of Medical Necessity in Clinical Documentation
This is where we document both the symptoms that we observe in session. So maybe tearfulness or physical agitation, as well as their reported symptoms. And last but not least, therapist interpretation: What do I think about what's going on? This is where we put on our clinical fancy hat and really evaluate all of these factors.
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