Most Googled Therapy Progress Notes Questions
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- Опубліковано 11 лип 2024
- You've probably searched for answers to your therapy progress notes questions online, but did you ever wonder what everyone else is searching, too?
In this livestream Dr. Maelisa McCaffrey of QA Prep will answer the three most commonly asked progress notes questions that lead mental health therapists to this channel!
1) Can insurance companies request therapy notes?
2) How soon do therapy notes need to be completed?
3) How to document a patient crying?
We also had some great follow up questions from the audience during the livestream:
-How long should an initial intake session note be? Should it be a report including all history, symptoms, etc.?
-How do you document when an adult patient states they are suicidal but doesn't appear sad?
-Any thoughts about documenting with psychodynamic type of therapy where goals are vague and the emphasis is more on interventions?
-What is a good way to phrase interventions like "clarify" and "process" that is acceptable to insurance?
Videos mentioned during the Q&A session...
5 Tips for Easier Psychotherapy Intakes: • 5 Tips for Easier Psyc...
Therapeutic Interventions List for 2023: • Therapeutic Interventi...
Need more help answering your questions about counseling progress notes? Schedule a one on one consultation with Maelisa here: www.qaprep.com/consultation-s...
Chapters
00:00 Introduction
01:53 Can insurance companies request therapy notes?
06:01 How soon do therapy notes need to be completed?
09:32 When are notes considered late?
10:12 How to document a patient crying?
14:22 How long should an initial intake session note be?
18:19 How do you document when an adult patient states they are suicidal but doesn't appear sad?
22:26 Any thoughts about documenting with psychodynamic type of therapy?
25:34 Why progress is the most important thing to focus on
28:58 What is a good way to phrase "clarify" and "process" that is acceptable to insurance?
What information should and should not go in a medical record when you provide counseling in a cancer center.
That really depends on the clinic's format. In most medical settings, the therapy progress notes are part of the general medical record and it's meant for continuity of care and treatment planning among the team. I would make sure your client is aware that you take notes and ask if they'd like to see them. This is an example where something like "history of sexual abuse" would be very relevant, but you may not want to include details beyond that.
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@@MaelisaMcCaffreythank you. I love watching you as most don’t go over the aspects you cover I. Your videos and it puts someone like myself at ease knowing it. Thank you so much.
If they’re crying, just put crying spells for symptom and/or intervention used for crying spells
I would actually just recommend "client cried" because "crying spells" may be interpreted as a judgement and indicates it's a more continuous behavior.
I usually write "tearful" as in "client was tearful" "client was tearful at moments" "client was tearful throughout"
@@wendyleeconnelly2939 This. I also always include 'congruent with content' after 'client was tearful at times/throughout' just to make clear that it's not lability or other abnormal crying