Rethinking Notes: Strategies for Making Documentation Simple and Meaningful

Course Materials

Part 2: Notes Strategies and Client Access
Part 3: Documenting for High Risk Populations

Syllabus

  • 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
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