Mental Health Documentation & Medical Necessity: Simple, Clear Guidelines that Maintain Quality of Care and Protect Your Practice
- Speaker:
- Beth Rontal, MSW, LICSW
- Duration:
- 6 Hours 51 Minutes
- Language:
- Presented in EN, subtitles in EN and FR, handouts in EN and FR
- Copyright:
-
Feb 28, 2025
- Product Code:
- POS055315
- Media Type:
- Digital Seminar
Description
“I love paperwork!”
--Said NO clinician, EVER.
Yet, the success of your practice depends on your ability to write good intake summaries, treatment plans, session notes, case/collateral notes, and discharge summaries. Taken together, these pieces to the documentation puzzle support your goal of providing quality services to your clients. They also impact the stability and success of your practice. When done well, they result in piece of mind and timely payment from insurance companies. When done poorly, they lead to the misery of denials, audits, and lost income.
The great news is that you CAN become proficient at mental health documentation and medical necessity. This seminar provides clear and simple guidelines for recordkeeping that adheres to professional standards and ethical codes, supports delivery of quality care, and reduces errors and delays in payments.
You will receive expert instruction from Beth Rontal, MSW, LICSW, affectionally known as the Documentation Wizard. For over 15 years, Beth has been instrumental at changing how individuals and organisations approach documentation. The results speak for themselves. Rates at which paperwork was returned to clinicians for correction have dropped significantly, in one case from 65% to under 8%. This gave clinicians back 3 to 5 clinical hours per week, saving thousands of dollars and improving job satisfaction.
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.
NOTE: Tuition includes one free CE Certificate (participant 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, and others.
Continuing Education Information: Listed below are the continuing education credit(s) currently available for this non-interactive self-study package. Program content is reviewed periodically per accrediting board rules for currency and appropriateness for credit. Credit approvals are subject to change. Please note, your licensing board dictates whether self-study is 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 purchase.
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 6.25 CE hours. Please see below, for more details, as credit amounts vary by jurisdiction and profession.
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 self-study activity is approved for 6.0 credit hours.
PESI, Inc. is approved by the Canadian Psychological Association to offer continuing education for psychologists. PESI, Inc. maintains responsibility for the program. This program is approved for 6.0 self-study continuing education hours. Full credit statement at: www.pesi.com/cpa-statement
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 6.25 Clinical continuing education credits.
Course Level: Intermediate Format: Recorded asynchronous 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 self-study activity qualifies for 6.25 continuing education clock hours 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.
This self-study course has been approved by PESI, Inc., as a NAADAC Approved Education Provider, for educational credits. NAADAC Provider #77553. PESI, Inc. is responsible for all aspects of their programming.
This self-study course offers 6.0 continuing education contact hours in the Documentation skill group. Full attendance is required; no partial credit will be awarded for partial attendance.
PESI, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. Nurses completing these self-study materials will earn 6.25 contact hours. Expires: 10/20/2027.
Handouts
| File type | File name | Number of pages | |
|---|---|---|---|
| Manual - Mental Health Documentation & Medical Necessity (13.3 MB) | 89 Pages | Available after Purchase | |
| Manual - Mental Health Documentation & Medical Necessity - French (13.3 MB) | 89 Pages | Available after Purchase | |
| Manual - Mental Health Documentation & Medical Necessity - Italian (13.3 MB) | 89 Pages | Available after Purchase | |
| Manual - Mental Health Documentation & Medical Necessity - German (13.3 MB) | 89 Pages | Available after Purchase | |
| Manual - Mental Health Documentation & Medical Necessity - Spanish (13.3 MB) | 89 Pages | Available after Purchase |
Speaker
Beth Rontal, MSW, LICSW Related seminars and products
Beth Rontal, LICSW, also known as the Documentation Wizard, spent 20 years as a theater costume designer before bringing her eye for structure and creativity to clinical work. Over 24 years as a trauma therapist, she discovered an unexpected passion: transforming the documentation clinician’s dread into a powerful clinical tool.
While supervising at a community mental health agency for 11 years, Beth developed a practical formula for treatment plans and progress notes that transformed her supervisees’ experience of note writing. In 2012, she founded Documentation Wizard® to help therapists turn clinical intuition into simplified, effective documentation. Her trainings and comprehensive forms – reviewed by attorneys and a bioethicist – and her work developing an electronic documentation system have empowered clinicians worldwide. Today, Beth has a private practice in Boston, MA specializing in emotional eating and is an internationally recognized speaker and consultant on mental health documentation.
Speaker Disclosures:
Financial: Beth Rontal maintains a private practice. She is the founder and trainer for Documentation Wizard, LLC. Beth Rontal receives a speaking honorarium and recording royalties from Psychotherapy Networker and PESI, Inc. She has no relevant financial relationships with ineligible organizations.
Non-financial: Beth Rontal is a member of the NASW.
Additional Info
Program Information
Access for Self-Study (Non-Interactive)Access never expires for this product.
For a more detailed outline that includes times or durations of time, if needed, please contact cepesi@pesi.com.
Questions?
Visit our FAQ page at https://www.pesicanada.ca/faq or contact us at https://www.pesicanada.ca/contact-us.
Objectives
- Determine the importance of proper documentation in informing clinical decision-making.
- Evaluate the role of the clinical diagnosis in justifying medical necessity and providing more effective services to clients.
- Determine how to use the behavioural language required by insurance companies to facilitate delivery of services to clients.
- Assess how to document what really happens in a clinical session without violating privacy or confidentiality.
- Assess medical necessity by employing the “golden thread” for improved treatment outcomes.
- Analyse potential red flags in documentation and the proper corrective measures for them.
Outline
Get Past Your Negative Feelings About Documentation- Documentation as a contributor to good clinical work
- Documentation through the lens of the “Golden Thread”
- Documentation as a protector of income and integrity
- Anxiety-reducing answers to common questions
- The elements of medical necessity
- The “Golden Thread” as a key part of medical necessity
- Establish the connection between diagnosis and treatment
- The Diagnostic Summary
- What’s needed in the diagnostic summary, and why
- How the diagnostic summary initiates the path of the Golden Thread
- The Treatment Plan
- What’s needed in a treatment plan, and why
- Operationalise the presenting problem
- Questions to ask
- Describe the diagnostic criteria in behavioural terms
- Make a clear connection between goals, objectives, and interventions
- Protect the client and the therapist with a thoughtful risk assessment
- Evaluate client progress
- How the treatment plan it continues the path of the Golden Thread
- And more …
- Activity: Write a treatment plan
- The Session Note
- The session’s note relationship to the treatment plan
- What’s needed in a session note and why
- Descriptive or narrative approach to interventions used
- Changes to treatment plan
- Justify multiple sessions
- Activity: Write a session note
- The Case and Collateral Contact Note
- What’s needed in a case and collateral contact note and why
- Differences between case and collateral contact notes
- Provide a clinical justification for the case/collateral consult
- The Discharge Summary
- What’s needed in a discharge summary, and why
- How the discharge summary completes the Golden Thread
Target Audience
- Mental Health Administrators
- Marriage and Family Therapists
- Physicians
- Psychiatrists
- Psychologists
- Counsellors
- Social Workers
- Office Managers
- Mental Health Nurses
- Addiction Counsellors
- Nurses
- Other Mental Health Professionals
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Overall: 4.8
Total Reviews: 6
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