Beth Rontal – Mastery in Mental Health Documentation & Medical Necessity

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Beth Rontal – Mastery in Mental Health Documentation & Medical Necessity

Although clinical documentation is a professional standard for care, there are not many guidelines on what or how to write it. It can feel disconnected from the work of helping clients. It can cause anxiety and confusion about privacy and confidentiality violations, potentially traumatic audits and even legal nightmares.

What criteria are required for a client to require services? How can medical necessity be justified? How can this be? “golden thread” Do you require documentation to be created and maintained in order to pass audits and maintain a professional standard of care even if insurance is not involved?

This recording can answer all of these questions and more. 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 not so scary. It is also confidential and ensures continuity of care.

Be a master of your misery and allow good documentation to be a contribution to high-quality clinical work, rather than a detour from it.

1. Explain the importance proper documentation in informing clinical decision-making.
2. Assess the role and importance of the clinical diagnosis in Justification of medical necessity and more effective services to clients
3. How to use the behavioral language required of insurance companies to facilitate delivery to clients
4. Explain how to document the real things in You can have a clinical session without revealing your identity or privacy.
5. Use the following tools to assess medical necessity “golden thread” For better treatment outcomes.
6. Identify potential red flags in Documentation and the corrective actions

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Why is this? Documentation What do Topic Clinicians Hate About?

• How do you feel about documentation
• Why is documentation so difficult?
• Why is documentation a topic that clinicians hate to hate?
• Why 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 for medical necessity

How to create a Treatment Plan

• Definition of a treatment program
• Everything that’s needed in A treatment plan and why
• How to create a treatment plan that justifies medical necessity using behavioral terminology and the “golden thread” Examples
• Write a treatment plan.

How to Write a Session Notable

• 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 need using behavioral language and the “golden thread” Examples
• Write a session note.

How to write an intake summary

• Definition of an intake summary and how it relates with all other documentation
• Everything that’s needed in An intake summary and why
• How to create an intake summary that lays the foundation for medical necessity

How to write case/collateral contact notes

• Definition of a Case/Collateral Contact Note and how it relates with the Treatment Plan
• Everything that’s needed in A case/collateral contact note with why
• How to create a case/collateral Note using behavioral language and the “golden thread” Examples

How to write a discharge summary

• Definition of a discharge summary, and how it relates with the treatment plan
• Everything that’s needed in A discharge summary and why
• How to write a summary of a discharge that completes the “golden thread” Examples