Documentation does not have to be overwhelming. We tend to write too much or not enough, but there are strategies for covering all the requirements while writing efficient yet comprehensive notes.

Clinical documentation is guided by your ethics code, legal, and regulatory requirements within context and jurisdiction. As clinicians we are responsible for our client's medical record content, confidentiality, maintenance, and security.

This workshop will move you from being overwhelmed and insecure about documentation to feeling confident in your charting. You can cover everything required without having to write a book in each progress note. Learn what you need to develop your own record keeping policies and procedures. This workshop is loaded with information on documentation essentials for clinicians in practice.

In this one day, in-person, workshop you will gain the following knowledge and skills:

1. Learn all the legal and ethical requirements for record keeping including Texas specific requirements

2. Learn the clinical form requirements: consent for services, confidentiality, release of information, and initial intake assessment

3. Learn what goes into treatment planning: goals and objectives made simple

4. Understand requirements for crisis assessment and safety planning documentation

5. Learn how to write a concise and objective progress note: framework, interventions, and clinical language

6. Understand the requirements for a discharge summary and written notification

7. Learn the billing requirements including DSM5, CPT codes, and insurance panel requirements

8. Identify medical necessity and the golden thread of documentation for your charting

9. Learn all the components required for passing an audit with confidence: tips and checklist

This workshop includes documentation samples and templates. We will practice documentation and interact with one another as a group for feedback. Your participation brings value, support, and accountability to the group.

This workshop offers 6 NBCC CE. This training is in-person from 9AM to 4PM with a one-hour lunch.

Lunch is provided for the group, as well as snacks, and beverages.

This group is limited to 6 psychotherapists of any level or licensure (LPC, LMFT, LCSW, LCDC, etc.).