Light Up The Couch FREE CE COURSE: The Ideal Progress Note: Myths, Methods, & Best Practices, Ep. 223
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Oct 9, 2024 Join Dr. Ajita Robinson, a counseling expert and insurance pro, along with Dr. Maelisa McCaffrey, a psychology innovator, Barbara Griswold, a marriage and family therapy guru, and Beth Rontal, a documentation whiz. They dive into the art and science of progress notes, busting myths and sharing best practices. Discover how to balance clinical necessity with client rapport, the impact of AI on documentation, and find out why thorough notes are vital for effective care. Embrace supportive structures to alleviate documentation stress and boost efficiency.
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Quality Over Quantity
- For a standard, 50-minute, non-crisis session, focus on quality over length.
- Ensure your progress note clearly demonstrates medical necessity.
Medical Necessity in Progress Notes
- Medical necessity means the client's condition requires professional intervention, not just everyday issues.
- Document the diagnosis, symptoms relating to that diagnosis, and tailored interventions.
Strategic Use of Client Quotes
- Use client quotes strategically, considering the context and potential interpretations.
- A hyperbolic statement about anger might be inappropriate, while a genuine threat requires documentation.