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

CAMFT Course Page

Course 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.

Credit Hours:
2 Hours

Learning Objectives:
The presentation will provide an overview of:
  • Name three common misconceptions that lead therapists not to write progress notes, or not to keep proper notes
  • Identify what California law says --and doesn't say -- about what needs to be in client progress notes
  • List 10 requirements that many insurance plans expect in provider charts.
  • Identify at least three therapy situations where it is especially important to document decisions carefully in case of a later complaint.
  • 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.
  • Identify two common reasons that records may be requested by an insurance plan.
The user acknowledges that the workshops, handouts, and related course materials contained therein are intended for educational purposes only, and should not be considered to be legal advice or a substitute for legal or clinical consultation. These presentations address issues that are multi-faceted, and the user should not assume that the courses discuss every law, regulation, or ethical code that may be relevant to the subject matter. Legal and ethical standards are subject to change and it is always prudent to check to see whether a particular law, regulation, or ethical standard may have changed.