Clinical Documentation Crash Course
Best Practices and AI-Assisted Tools to Write Quick, Ethical and In-Compliance Notes
- Speaker:
- Andrew Huber, MA, LMFT
- Duration:
- 4.25 Hours
- Language:
- Presented in EN, subtitles in EN and FR
- Product Code:
- LWC150810
- Brochure Code:
- PWZ95881
- Media Type:
- Live Webinar - Also available: Digital Seminar
Description
Write Better Notes, Save Time and Safely Use AI-Assisted Tools … all in one Fast-Track 4 Hour Program
- Write progress notes in 5-7 minutes without losing clinical depth
- Create documentation that clearly demonstrates medical necessity
- Understand legal and ethical standards
- Use AI wisely: what’s ethical, what’s risky, and what truly helps
You want to stay present with clients … but the moment your last session ends, the notes start piling up.
Progress notes, treatment plans, and medical necessity documentation can quickly become overwhelming.
And with the rise of AI-assisted tools things are getting even more confusing …
…What’s allowed? What’s ethical? What’s safe? What actually helps?
That’s why we teamed up with Andrew Huber, LMFT, a seasoned clinician and co-founder of Therapy Self, a platform focused on streamlining documentation. Andrew has the tips, tools and strategies for busy clinicians who want:
- Clear, confident, defensible documentation
- Efficient workflows that save hours each week
- Ethical guidance on using AI
- Real-world examples and walk-throughs
In this 4-hour training he’ll share all he knows with you, so you can create notes that tell the clinical story, demonstrate progress, strengthen treatment planning, and support high-quality client care …
… Plus how you can use AI-assistance to help create notes faster and better than ever – all legally and ethically compliant.
If you want to feel in control of your notes, not behind on them, this course is for you.
Register now!
Credit
Program Information
Planning Committee Disclosure - No relevant relationshipsAll members of the PESI, Inc. planning committee have provided disclosures of financial relationships with ineligible organizations and any relevant non-financial relationships prior to planning content for this activity. None of the committee members had relevant financial relationships with ineligible companies or other potentially biasing relationships to disclose to learners. For speaker disclosures, please see the faculty biography.
AI Use Disclosure
A small portion of the material for this CE activity was developed with limited assistance from generative AI. All AI-generated information was reviewed for accuracy by the instructor, an independent content reviewer, or PESI staff.
NOTE: Each purchase includes CE credit for one individual (participants in full attendance will be able to print the certificate of completion after passing the online post-test (80% passing score) and completing the evaluation). Instructional methods will include PowerPoint, didactic lecture, Q&A, and others.
Continuing Education Information: Credits listed below are for full attendance at the live, interactive webinar only. This webinar is being broadcast live in real-time and must be attended live, in its entirety, in order to earn credit. You will be able to type questions to the speaker. The speaker will see the questions and address them during the presentation as time allows. Please note, your licensing board dictates whether web-based activities are an acceptable form of continuing education, as well as which credit types are acceptable for continuing education hours. Please refer to your licensing board's rules and regulations. If your profession is not listed, please contact your licensing board to determine your continuing education requirements and check for reciprocal approval. For other credit inquiries not specified below, please contact info@pesi.com or 800-844-8260 before the event.
Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of your profession. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your profession's standards.
For Planning Committee disclosures, please see the statement above. For speaker disclosures, please see the faculty biography.
Earn up to 4.0 CE hours. Please see below, for more details, as credit amounts vary by jurisdiction and profession.
THIS ACTIVITY QUALIFIES FOR 1.0 HOURS OF GENERAL ETHICS INSTRUCTION. Not all boards allow ethics credit for on-line programs. If ethics is not specified within your licensing board’s approval statement below, please contact your board to determine the applicability and amount of ethics allowed.
PESI, Inc. is approved by the Canadian Counselling and Psychotherapy Association to offer continuing education for counsellors and psychotherapists. PESI, Inc. maintains responsibility for the program. This activity is approved for 4.0 credit hours.
PESI, Inc., #1062, is approved as an ACE provider to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE provider approval period: January 27, 2026 - January 27, 2029. Social workers completing this course receive 4.0 Clinical continuing education credits.
Course Level: Intermeediate Format: Synchronous Distance. Full attendance is required; no partial credits will be offered for partial attendance.
Canadian Social Workers: Canadian provinces may accept activities offered by providers approved by the ASWB ACE program for ongoing professional development.
This activity qualifies for 240 continuing education minutes as required by many national and local licensing boards and professional organizations. Save your activity advertisement and certificate of completion, and contact your own board or organization for specific requirements.
PESI, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. Nurses in full attendance will earn 4.0 contact hours. Partial contact hours will be awarded for partial attendance.
Speaker
Andrew Huber, MA, LMFT Related seminars and products
Andrew Huber, MA, LMFT, is a licensed marriage and family therapist with over a decade of clinical and administrative experience in mental health care. He has spent nine years working in private group practice and eight years in adolescence psychiatric settings, where he developed a deep understanding of effective and defensible clinical documentation. As the clinical co-founder of Therapy Shelf, an innovative software platform designed to help therapists streamline documentation, Andrew brings a unique blend of clinical expertise, systems thinking, and technical insight. He is passionate about teaching therapists how to write clear, efficient, and ethical documentation that strengthens both clinical care and professional confidence.
Speaker Disclosures:
Financial: Andrew Huber has employment relationships with Sycamore Grove and Therapy Shelf. He receives a speaking honorarium from PESI, Inc. He has no relevant financial relationships.
Non-financial: Andrew Huber is a member of the California Association of Marriage and Family Therapists.
Additional Info
Program Information
Access Period for Live WebcastYou will have access for 90 days after the program for review. For live CE credit, you must watch the live webcast in its entirety at its scheduled time and complete the CE quiz and evaluation within one week. Please note that this requirement may vary by credit type. Please see detailed credit information for specific requirements for each credit type.
Webcast Schedule
Please note: There will be a 15-minute break mid-morning. Actual break start times are at the discretion of the speaker. A more detailed schedule is available upon request.
Questions?
Visit our FAQ page at https://www.pesicanada.ca/faq or contact us at https://www.pesicanada.ca/contact-us.
Objectives
- Analyze the ethical, legal, and regulatory standards that guide clinical documentation and medical necessity.
- Develop progress notes that clearly document interventions, client response, and clinical rationale.
- Choose treatment plan goals that are measurable, client-centered, and interconnected with progress notes.
- Differentiate between ethical and unethical use of AI in clinical documentation, including risk areas related to HIPAA, confidentiality, and PHI.
Outline
Documentation Formats
Learn how to choose the right note structure so your documentation is clear, consistent, and audit-ready
- Purposes of progress notes
- Different formats of documentation including SOAP, DAP, and BIRP
- Risks, research and limitations
Progress Notes: Writing Clear, Defensible Notes
Master writing progress notes that are complete, defensible, and efficient – without wasting time or over-documenting
- Essentials in a progress note
- What auditors and insurers expect
- How much detail is enough for medical necessity
- Establishing notes level of granularity
- Words that trigger red flags
- Completeness checklist
Treatment Plans: Link Goals to Documentation
Create treatment plans that align with client goals, meet payer standards, and stay easy to update as needs change
- Essentials in a treatment plan
- Establishing plans level of granularity
- Adjusting treatment plans
Ethical HER and AI: How to Work Smarter without Risk
Discover safe, ethical ways to use EHR systems and AI tools to speed up documentation without risking compliance or client privacy
- Safety strategies with EHRs
- Basics of AI notetaking capacities
- Reviewing AI notes
Other Types of Clinical Documentation
Understand the differences between progress notes, psychotherapy notes, scratch notes, and chart notes – so you never mix them up
- Progress vs. psychotherapy notes – legal and clinical differences
- Scratch notes & chart notes – What belongs where – and what never should
- Risk of mixing note types – how mistakes lead to audits or lawsuits
Quick Tips
Get practical strategies to write faster, stay organized, and build a workflow that saves hours every week
- Speeding up notes
- Using templates
- Batch documentation
- Staying accountable for documentation
Target Audience
- Counselors
- Social Workers
- Marriage and Family Therapists
- Psychologists
- Registered Psychotherapists
- Physicians
- Psychiatrists
- Mental Health Nurses
- Addiction Counselors
- Other Mental Health Professionals
Reviews
Satisfaction Guarantee
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