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What Should Be In Your Client Charts-And Probably Isn't: Writing Great Progress Notes & Treatment Plans

Presented by Barbara Griswold, LMFT – 2 CE Hours

Workshop Description

While therapists may shiver at the idea of an insurance plan reviewing a client's chart, records requests are happening more frequently, even to therapists who aren't affiliated with a healh plan. Without proper documentation of medical necessity for treatment, goals, and interventions, insurance may not cover necessary treatment. Attendees will learn how to write notes that will assist in treatment, as well as to meet the expectations of state law, professional ethics, licensing boards, and insurance plans, as well-written records can be a therapist's best defense.

Learning Objectives
Upon completion of this video workshop, attendees will be able to:
1. Name three common misconceptions that lead therapists not to write progress notes, or not to keep proper notes
2. Identify what California law says --and doesn't say -- about what needs to be in client progress notes
3. List 10 requirements that many insurance plans expect in provider charts.
4. Identify at least three therapy situations where it is especially important to document decisions carefully in case of a later complaint.
5. Be able to define the concept of "medical necessity for treatment," and how this important concept must be documented in order to assist clients in getting insurance coverage for needed treatment.
6. Identify two common reasons that records may be requested by an insurance plan.