Rethinking Notes: Strategies for Making Documentation Simple and Meaningful

2 CE Credit Hours. Legal-Ethical. Continuing Education Session Replay

Presented By: Maelisa McCaffrey (Hall), PsyD


Few psychotherapists receive training in documentation during internship and graduate school. This leads many licensed clinicians to learn on their own and through experience. In this presentation you’ll learn the most common mistakes that psychotherapists make with their documentation and what leads to these mistakes. Most importantly though, you’ll learn what to do instead and how to make documentation a stress-free process in any clinical setting.

Course Description

Educational Objectives

  • Identify the most common mistakes in documentation
  • Describe at least 3 strategies for creating high quality notes
  • Define client’s access to records based on HIPAA, OpenNotes, and other applicable laws and ethics
  • Explain how to save time on notes without negatively impacting clinical quality
  • Describe how to document high risk issues, outside of session communication, and notes for special populations (couples, family, etc.)


  • Introductions
  • Common mistakes in documentation
    • Writing too much
    • Writing too little
    • Over focusing on insurance
    • Forgetting to include insurance requirements
  • Strategies for high quality notes
    • Using a personalized and consistent template
    • Considering the clinical meaning for all the potential readers
    • Writing in a timely manner
    • Communication outside of sessions
  • Strategies for saving time on notes
    • Including other documentation with your notes
    • Including your client in the process
  • Client access to records
    • HIPAA
    • OpenNotes
    • Collaborative documentation
  • Documenting high risk issues and for specialty populations
    • High risk issues
    • Couples and families
    • Children and adolescents
  • Q&A, Closing Comments


  • American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. Washington, DC: Author.
  • American Psychological Association. (2009). Criteria for the Evaluation of Quality Improvement Programs and the Use of Quality Improvement Data. American Psychologist. September Vol 64 Number 6, Pages 551-557.
  • Griswold, G. (2015) Navigating the Insurance Maze. San Jose, CA: Paper Street Press.
  • Luepker, E.T. (2012) Record Keeping in Psychotherapy and Counseling. New York, NY: Routledge, Taylor and Francis Group.
  • Schwitzer, A.M. & Rubin, L.C. (2015) Diagnosis & Treatment Planning Skills. Thousand Oaks, CA: SAGE Publishing.
  • Sutton, R. (2016) The Counselor’s STEPs for Progress Notes. San Bernardino, CA: Self Published.
  • 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.
  • Wiger, D.E. (2012) The Psychotherapy Documentation Primer, 3rd Edition. Hoboken, NJ: John Wiley & Sons, Inc.
  • Zuckerman, E.L. and Kolmes, K. (2017) The Paper Office for the Digital Age. New York, NY: The Guilford Press.
2 CE Credit Hours.

Presented/Developed By

Dr. Maelisa Hall is a licensed psychologist, nail design enthusiast, and multi-passionate entrepreneur. With her business QA Prep, she empowers therapists through trainings 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. 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.

Program Notices

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. Hall 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.

This course is subject to our cancellation/refund policy and complaint policy.

2 CE Credit Hours.

2 CE Credit Hours. Legal-Ethical. Continuing Education Session Replay


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