Self Study Online Course
The Complete Guide to Documentation for Trauma Informed Therapists provides simple, easy to implement guidelines on clinical documentation - specifically designed for trauma therapists.
From intake to discharge, you’ll have a clear understanding of what to include in your charts and how to document everything. Plus, I’ll give you templates to make it easy to get started.
Learning Objectives
After this training, you will be able to:
+ Learn the essential information required in your medical records for comprehensive and compliant documentation
+ Learn the importance of clinical documentation in trauma therapy
+ Develop SMART goals to create treatment plans that not only drive patient progress but also resonate with insurance providers.
+ Document medical necessity for 90837 sessions to protect you from audits
+ Provide adequate justification for 90785 interactive complexity to increase your reimbursement amounts for complex interactions.
+ Develop a comprehensive understanding of CPT codes for therapy and their associated time constraints, ensuring you optimize billing and reimbursement.
+ Craft trauma session documentation that aligns seamlessly with insurance requirements
+ Gain clarity on distinguishing psychotherapy notes from progress notes
+ Learn the 'Golden Thread' of clinical documentation and how it aids in creating a seamless narrative that enhances client care, bolsters compliance, and secures reimbursement.
Module 1: Introduction
Module 2: Medical Record Essentials
Module 3: Intake Assessment
Module 4: Diagnosis and Treatment Plans
Module 5: Progress Notes
Module 6: Discharge Notes
Module 7: Contact notes, Psychotherapy Notes, & Risk Management Notes
Handouts You Will Receive
+ 2 Intake Assessment note templates
+ Progress Note Template
+ 2 Discharge Note Templates
+ Most Commonly Used ICD-10 Codes
+ Medical Necessity Justification for 90837 Extended Psychotherapy Sessions
+ Justifications for 90785 Interactive Complexity Add-on
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