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Beth Rontal – Mastery in Mental Health Documentation & Medical Necessity
The professional standard of care for clinical documentation is not easy to understand. However, it is possible to get some guidance on what and how to document the process. Helping clients can seem to be separated from paperwork. It can lead to anxiety and confusion regarding privacy and confidentiality violations.
What criteria should a client meet to be eligible for services? What is the justification for medical necessity? How does one justify medical necessity? “golden thread” Is it important that documentation is created and maintained in order to pass audits and maintain a professional standard even when there is no insurance?
These questions and many more can be answered by this recording. It is not difficult to create effective clinical documentation. It’s a simple formula that once you know it, can transform clinical thinking into clear documentation. Treatment plans and notes can be written quickly and efficiently so that authorizations can be obtained quickly. Audits are also not as scary. It is also confidential and ensures continuity of care.
Do not allow misery to stop you from mastering your life. Instead, let good clinical documentation help to make high-quality clinical work possible.
- Define the importance of documentation in informing clinical decision-making.
- Assess the role of clinical diagnosis in Clients can be justified by medical necessity.
- Learn how to use behavioral language that insurance companies require to provide services to clients.
- How to document what actually happenss in You can have a session with a clinician without having to reveal any of your private information.
- Use the following tools to assess medical necessity “golden thread” For better treatment outcomes.
- Identify red flags in Documentation and corrective actions
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Why is it? Documentation What do Topic Clinicians Hate About?
- Do you have a view on documentation?
- What is the point of documentation?
- What is it that clinicians hate about documentation?
- Why should you document?
Medical Necessity
- Definition of Medical Necessity
- What is it? “The Golden Thread” What does it have to do with medical necessity?
- What is the role and function of diagnosis in Justification for medical necessity
How to write a treatment plan
- Definition of a treatment program
- Everything that’s needed in What is a treatment plan?
- How to use behavioral language and the APA style to create a treatment program that justifies medical necessity “golden thread” With examples
- Practice writing a treatment program
How to write a session note
- Definition of a session Note and its relationship to the treatment plan
- Everything that’s needed in A session note and why
- How to create a session note that justifies medical necessity by using behavioral language and the “golden thread” With examples
- Practice writing session notes
How to create an Intake Summary
- Definition of an intake summary, and its relationship to all documentation
- Everything that’s needed in A summary of intake and why
- How to write an intake summary that is a basis for medical necessity
How to create case/collateral notes
- Definition of a case/collateral note and its relationship to the treatment plan
- Everything that’s needed in A case/collateral note with why
- How to create a case/collateral contact note that justifies medical necessity using behavioral terminology and the “golden thread” With examples
How to write a discharge summary
- What is a discharge summary? How does it relate to the treatment plan?
- Everything that’s needed in A discharge summary and why
- How to create a summary of a discharge that is complete “golden thread” With examples
Course Features
- Lectures 0
- Quizzes 0
- Duration Lifetime access
- Skill level All levels
- Students 168
- Assessments Yes