Abundant Practice Podcast Episode #661: Avoiding Clawbacks - Private Practice Notes 101, feat. Dr. Tiana Kelly
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Jun 25, 2025 Dr. Tiana Kelly, a seasoned clinician and expert in documentation, shares vital insights about HIPAA and insurance protocols in private practice. She highlights common documentation pitfalls, such as late notes and miscoding, and offers practical strategies for creating clear, compliant records. Tiana emphasizes the balance between detailed and skeletal notes and the importance of timely documentation to avoid financial setbacks. She also discusses the potential pitfalls of AI-generated notes, ensuring that quality care remains the priority in clinical settings.
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Essential Note Components
- Include mental status exam data and observations in every note.
- Document interventions connected to goals and plans between sessions to justify treatment.
Balancing Note Detail
- Tiana and Allison shared experiences from sexual assault centers and partial hospitalization.
- They emphasized balancing detailed and skeletal notes depending on setting and client safety.
Notes Protect Your Practice
- Always take thorough notes regardless of insurance or private pay.
- Notes protect therapists by documenting important conversations and agreements.