2 CE Credit Hour Presentation on Treatment Plans
Foundations of Documentation: Intake, Diagnosis, and Treatment Plans
Self-study on-demand CE course
Join Dr. Maelisa McCaffrey as she gives you practical tools for managing all the documentation related to new clients – informed consent, intake paperwork, assessment and diagnosis, and creating treatment plans. You’ll also learn how to incorporate client feedback, build rapport, and connect with clients throughout these paperwork heavy tasks.
Plus: Dr. McCaffrey’s documentation packet to help you improve your notes including:
- Diagnosis Justification Examples
- Treatment Plan Template
- Sample Treatment Goals List
2 legal ethical CE credit hours
On-Demand CE Course
Real feedback from the live event:
“This was great. Maelisa is full of great information and presents it in a non-judgmental and helpful way. Very glad to do trainings with her!”
“This was one of the most helpful trainings I’ve attended, thank you”
“Maelisa, you are the embodiment of excellence. Thank you for your clarity, and for sharing so generously what you know.!”
“am leaving behind…a little less stress. I am taking with me….start doing something today to lower stress about treatment plans and documentation.”
Documentation Bundle
Create systems for both intake and treatment planning that can save you hours on clinical documentation.
Sign up today and prepare to leave with an actionable plan that instills confidence in your documentation.
Do you view intake sessions and treatment plans as time-consuming paperwork tasks that take up hours?
Do you frequently fall behind in paperwork when you have an intake session during the week?
Let’s solve that problem together!
This online workshop will give you practical tools for managing all the documentation related to new clients – informed consent, intake paperwork, assessment and diagnosis, and creating treatment plans. You’ll also learn how to incorporate client feedback, build rapport, and connect with clients throughout these paperwork heavy tasks.
Have your own intake paperwork and treatment plan templates ready so you can make adjustments to your documentation in real time. You’ll learn how to balance the process part of these important clinical tasks, along with the necessary documentation requirements for intakes and treatment plans.
You will also practice writing treatment goals and have the opportunity to get feedback and ask questions throughout the workshop. Learn well-tested strategies that work for clinicians across the spectrum of neurodivergence, and apply to any client population.
Who is this event for?
This course is designed for solo practitioners, group practice leaders, and group practice clinical staff members. It is also suitable for practices that consist of 100% in-person, 100% telehealth, or a mixture of in-person and telehealth treatment.
Additionally, this is designed to help mental health professionals write with clarity, efficiency, and care – empowering you to maintain compliance, reduce risk, and enhance your therapeutic work. Bring your questions and come prepared for an interactive and common sense presentation that will provide tools you can use immediately.
In-person Practices
Hybrid Practices
Teletherapy Only Practices
Plus a Documentation Pack to Improve Your Notes:
- Diagnosis Justification Examples
- Treatment Plan Template
- Sample Treatment Goals List
I’ve been watching several of your CE programs and, while I’ve always been impressed with your services, I just have to say, your programs are excellently done with production and content and simultaneously warm and accessible. I really appreciate what you do!
Client Centered Documentation
Identify one strategy to save time while building therapeutic rapport during intake assessments.
Medical Necessity
Explain how to justify diagnostic criteria for medical necessity.
Documentation Requirements
Practice writing meaningful treatment goals that meet insurance criteria.
Course Details
2 CE Credit Hour. Self Study
Title: Foundations of Documentation: Intake, Diagnosis, and Treatment Plans
Authors/Presenters: Dr. Maelisa McCaffrey, PsyD
CE Length: 2 CE credit hours, legal-ethical
Legal-Ethical CE Hours: 2 legal-ethical CE hour
Educational Objectives:
- Identify one strategy to save time while building therapeutic rapport during intake assessments.
- Explain how to justify diagnostic criteria for medical necessity.
- Practice writing meaningful treatment goals that meet insurance criteria.
Syllabus:
- Introductions
- Intake assessment as the foundation for documentation
- Including your client in the process
- Diagnosis and FIDO
- Ongoing assessment and complex cases
- Diagnosis justification examples
- Writing simple and meaningful treatment plans
- Review of potential treatment plan components
- Using client collaboration effectively
- Creating easy, high-quality treatment goals
- Treatment plan and treatment goal updates
- Final review and Q&A
Note: Yes! Medical necessity will be addressed in this presentation.
Meet Our Presenters
Presented by
Dr. Maelisa McCaffrey, PsyD
Dr. Maelisa McCaffrey is a licensed psychologist, nail design enthusiast, and multi-passionate entrepreneur. With her business QA Prep, she empowers therapists with training and consultation on clinical documentation. Maelisa focuses on the “why” behind the usual recommendations and encourages clinicians to think outside the box, while also keeping their ethics intact. As a true ENFP, Maelisa aims to make sure all of her endeavors are meeting a need in the community while also allowing for plenty of laughter and fun.
Website/Business Links:
QA Prep https://www.qaprep.com/
Resources & Citations
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- APA Dictionary of Psychology. (2023, November 15). Informed consent. American Psychological Association. https://dictionary.apa.org/informed-consent Chow, D. (2018). The First Kiss: Undoing the Intake Model and Igniting the First Session in Psychotherapy. Correlate Press.
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McCaffrey, M. (2024). Using Artificial Intelligence (AI) as a Mental Health Clinician: Managing risk, ethics, and clinical benefits. - Nagy, G.A., Cassiello-Robbins C., Anand, D., Arnold, M., Coleman, J., Nwosu, J., Singh, R., and Woodward, E. (2022). Building a multicultural peer-consultation team: Planning, implementing, and early sustainment evaluation. Transcultural Psychiatry, 59(6), 844-862. doi:10.1177/13634615221105117
- Nathan, W. & Desposito, M. (2023, October). The benefits of clinical consultation groups. American Counseling Association. https://www.counseling.org/publications/counseling- today-magazine/article-archive/article/legacy/the-benefits-of-clinical-consultation-groups
- National Association of Social Workers. (2021). NASW Code of Ethics. https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English#principles
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- Office of the National Coordinator for Health Information Technology. (n.d.). Retrieved March 17, 2024 from https://www.healthit.gov/faq/what-electronic-health-record-ehr
- Onyeaka, H., Ajayi, K. V., Muoghalu, C., Eseaton, P. O., Azuike, C. O., Anugwom, G., Oladunjoye, F., Aneni, K., Firth, J., & Torous, J. (2022). Access to online patient portals among individuals with depression and anxiety. Psychiatry Research Communications, 2(4), Article 100073. https://doi.org/10.1016/j.psycom.2022.100073
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- Sabri, B., Tharmarajah, S., Njie-Carr, V. P. S., Messing, J. T., Loerzel, E., Arscott, J., & Campbell, J. C. (2022). Safety Planning With Marginalized Survivors of Intimate Partner Violence: Challenges of Conducting Safety Planning Intervention Research With Marginalized Women. Trauma, violence & abuse, 23(5), 1728–1751. https://doi.org/ 10.1177/15248380211013136
- Schwarz, J., Bärkås, A., Blease, C., Collins, L., Hägglund, M., Markham, S., & Hochwarter, S. (2021). Sharing Clinical Notes and Electronic Health Records With People Affected by Mental Health Conditions: Scoping Review. JMIR Mental Health, 8(12), e34170. https://doi.org/10.2196/34170
- US Dept. of Health and Human Services. (2006). HIPAA Administrative Simplification. Washington, DC: Author.
- US Dept. of Health and Human Services. (2013). HIPAA Omnibus Final Rule. Washington, DC: Author.
- van Rijt, A. M., Hulter, P., Weggelaar-Jansen, A. M., Ahaus, K., & Pluut, B. (2021). Mental Health Care Professionals’ Appraisal of Patients’ Use of Web-Based Access to Their Electronic Health Record: Qualitative Study. Journal of Medical Internet Research, 23(8), e28045. https://doi.org/10.2196/28045
Accuracy, Utility, and Risks Statement: The contents of this program are based primarily on the presenters’ extensive combined experience handling legal, ethical, and usable paperwork needs for mental health organizations. Statements about applicability are according to presenters’ understanding of the state of the art and legal precedents at the time of presentation. This program discusses strategies for complying with applicable ethics codes and laws, for improving clinical documentation, and the informed consent process. It may not include information on all applicable state laws. Misapplication of the materials, or errors in the materials, could result in non-compliance with applicable laws or ethics codes.
Conflicts of Interest: Dr. McCaffery is the CEO of QA Prep, an organization which provides additional resources and consultation on clinical documentation for mental health professionals, which may be mentioned as an optional resource for learners.
Commercial Support: none.