Are Your Medical Records Holding you Back in Private Practice? [Show Notes]

Transcript for “Are Your Medical Records Holding you Back in Private Practice?”

Note: This video is transcribed using AI therefore some errors have occurred in the transcription of this video.

All right, so you are working your private practice, you are seeing clients and things are going well, right? That’s fantastic! I want to take a moment to take a pause and look at quality of care versus the quantity that you’ve been working on so far, and I want to take a moment to really look at that from a medical records clinical documentation perspective.

Now, if you are brand new to this field in general and have never written a note, here’s a little bit of a one-on-one. As a private practice practitioner, you are essentially kind of medical staff but just from that mental health perspective, so you will be keeping a medical record of your work with your clients. That’s going to include some type of intake assessment, where you are screening them, looking at what their needs are, and assessing how either you’re going to help or how you’re going to connect them to the needed help.

Every session that you do with them, you’re going to be writing some type of note to document what interventions were completed during that time and how it links to your goals. You will have an overarching treatment plan that outlines specifically what the client’s goals are and how you and the client are going to work together on those goals. Every 90 days or so, you’re going to be reviewing that treatment plan, seeing what’s working, seeing what’s not working, celebrating the wins, but also looking at the barriers and any changes that need to be made to that treatment to help them progress further in their goals and their wellness.

Once treatment is completed, you’re going to be writing a discharge note, something that wraps up the work that you’ve done with them, and hopefully, it’s a successful discharge and you’re saying that they’re happy, they’re healthy, they’re on their way. But you’re even writing a discharge note if things don’t go as intended and you need to refer out to a higher level of care. There are a bunch of other supplemental notes in there like a chart note.

There’s a what is a Psychotherapy note, which is not in the medical record but something that you might want to keep yourself if you’re sending letters to clients, how to do that properly and quickly so you’re not spending all your time writing letters when you already have enough on your plate with treating and documenting. If this is something that you’re struggling with, it really can be a confidence killer as you’re growing your practice.

And also, I mean, you really want this to shine well because other professionals could potentially be reading it as well as the client, and you want your documentation to reflect the good work that you’re doing. So, if this is something that you’re struggling with, I do offer a course that is tailored specifically to what is in clinical documentation, how do you kind of display medical necessity. I highly recommend you checking that out. I will link to it below.

This way, if you need either a tune-up or you need a crash 101 course, it is there for you because it is an important skill that is needed for private practice that isn’t always spoken about in grad school. You might have already had some experience with it if you’re coming from an agency work, but now that you’re on your own, you do want to make sure that your documentation is tip-top shape.

So again, if you need help with it, there’s a link down below. Hopefully, you have a system that’s working for you, and if so, fantastic! Keep doing it right, don’t break what’s not broken. But I just wanted to throw out what is available to you if you did need a little extra help in that area. All right.

Mastering Clinical Documentation With Speed and Efficiency (includes templates) https://www.stresslesstherapist.com/documentation-course

Progress Note Planners (affiliate links)

• The Child Psychotherapy Progress Notes Planner
• The Adolescent Psychotherapy Progress Notes Planner
• The Adult Psychotherapy Progress Notes Planner
• The Severe and Persistent Mental Illness Progress Notes Planner

Treatment Planning Planners (affiliate links)

• The Family Therapy Treatment Planner
• The Complete Adult Psychotherapy Treatment Planner
• The Adolescent Psychotherapy Treatment Planner
• The Addiction Treatment Planner
• The Child Psychotherapy Treatment Planner
• The Couples Psychotherapy Treatment Planner
• The Parenting Skills Treatment Planner
• The Severe and Persistent Mental Illness Treatment Planner
• The Crisis Counseling and Traumatic Events Treatment Planner
• The Co-Occurring Disorders Treatment Planner
• The Family Therapy Treatment Planner
• The Group Therapy Treatment Planner
• The Social Work and Human Services Treatment Planner
• The Suicide and Homicide Risk Assessment and Prevention Treatment Planner
• The Veterans and Active Duty Military Psychotherapy Treatment Planner
• The Juvenile Justice and Residential Care Treatment Planner

Show Links for “Are Your Medical Records Holding you Back in Private Practice?”

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