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Digital Seminar

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 relationships

All 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.



Canada Credit - *

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.

 


Canada Credit - ---

Earn up to 6.25 CE hours. Please see below, for more details, as credit amounts vary by jurisdiction and profession. 


Canada Credit - Canadian Counsellors and Psychotherapists

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.


Canada Credit - Social Workers - National ASWB ACE

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, 2023 - January 27, 2026. 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 approved by the ASWB for ongoing professional development.


Canada Credit - Canadian Psychologists

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


Canada Credit - Other Professions

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.


US National Boards - Addiction Counselors - NAADAC

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.


US National Boards - Nurses, Nurse Practitioners, and Clinical Nurse Specialists – ANCC

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

Speaker

Beth Rontal, MSW, LICSW's Profile

Beth Rontal, MSW, LICSW Related seminars and products


Beth Rontal, MSW, LICSW, is a psychotherapist in private practice in Brookline, Massachusetts, as well as a documentation consultant (wizard) and private supervisor. Ms. Rontal earned her MFA from Boston University, and her Master’s in Social Work from Simmons College in Boston.

She was clinical supervisor at a mental health clinic for 16 years, where she was instrumental in developing and implementing the clinic’s first electronic documentation system. This implementation significantly reduced documentation time and errors and decreased the paperwork returned by clinicians from 65% to 8%, which in turn allowed for the addition of 3 to 5 clinical hours per week and generated thousands of dollars in savings for the company. 

 

Ms. Rontal continues to be a developer and consultant in the field of clinical documentation. She is a sought-after national lecturer who has taught seminars over the course of many years, in addition to having published numerous articles on the topic. 


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

  1. Determine the importance of proper documentation in informing clinical decision-making.
  2. Evaluate the role of the clinical diagnosis in justifying medical necessity and providing more effective services to clients.
  3. Determine how to use the behavioural language required by insurance companies to facilitate delivery of services to clients.
  4. Assess how to document what really happens in a clinical session without violating privacy or confidentiality.
  5. Assess medical necessity by employing the “golden thread” for improved treatment outcomes.
  6. 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
Embrace the Requirement of Medical Necessity
  • The elements of medical necessity
  • The “Golden Thread” as a key part of medical necessity
  • Establish the connection between diagnosis and treatment
How to Write:
  • 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
20 DOCUMENTATION RED FLAGS THAT LEAD TO TROUBLE

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

Reviews

5
4
3
2
1

Overall:      4.8

Total Reviews: 6

Comments

Erin W

"Beth was wonderful and I would take any training from her again in the future, she made it very accessible. This was extremely useful for my practice."

LaWanda A

"OUTSTANDING COURSE!! "

Susan B

"Definitely worth the money!"

Matthew D

"None"

Judi T

"Live Stream was excellent quality and easy to use. So happy I had that option!"

Patricia B

"I am impressed with the level of information provided in this presentation. Beth demystified so much around documentation: I especially enjoyed the video and creating the treatment plan, it could have been mine. Thank you, clearly others struggle with documentation like I do. I will start using Beth’s methods of documentation. Thank you Beth😇"

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