What You’ll Discover in Beth Rontal Mastery in Mental Health Documentation & Medical Necessity
Available for purchase. This course is available to you.
Beth Rontal – Mastery in Mental Health Documentation & Medical Necessity
Although clinical documentation is an important part of professional care, there are not many guidelines on how to do it. It can feel disconnected from the work of helping clients. It can lead to anxiety and confusion regarding privacy and confidentiality violations.
What are the requirements for a client who requires services? What is the justification for medical necessity? What is the best way to ensure that medical necessity is justified? “golden thread” Is it important that documentation is created and maintained in order to pass audits and maintain a professional standard even if there is no insurance?
This recording will answer all of these questions. It is not difficult to create effective clinical documentation. Once you have mastered it, you can translate clinical thinking into clear documentation. This allows for quick and efficient treatment planning and note writing. Authorizations are easy to obtain and audits are less scary. The confidentiality of the patient is maintained and continuity of care is guaranteed.
Be a master of your misery, and let good documentation be a contribution to quality clinical work instead of a distraction.
- Explain the importance and benefits of proper 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.
- Describe how to document the real thingS in You can have a session with a clinician without having to reveal any of your private information.
- The following steps can be used to determine 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?
- Why is documentation so difficult?
- Why is documentation so hated by clinicians?
- 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 purpose of the diagnosis? in Justification of medical necessity
How to write a treatment plan
- Definition of a treatment strategy
- Everything that’s needed in What is a treatment plan?
- How to create a treatment plan that justifies medical necessity by using behavioral language and the “golden thread” With examples
- Practice writing a treatment program
How to create a session note
- Definition of a session Note and its relationship to the treatment plan
- Everything that’s needed in A session note with why
- How to write a session not that justifies medical necessity using behavioral terminology and the “golden thread” With examples
- Write a session note.
How to write an intake summary
- Definition and relationship of the intake summary to all other documentation
- Everything that’s needed in A summary of intake and why
- How to create an intake summary that establishes medical necessity
How to write case/collateral contact 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 make a Case/Collateral Contact Note that justifies medical need using behavioral language and/or 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
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