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There are a ton of questions that most behavioral health professionals have related to completing and managing clinical documentation. There are a wide range of opinions around what is needed in a treatment record and the best ways to do it. Documentation Station, hosted by clinical documentation consultant Steven Welton, LCPC, focuses on the detailed standards for clinical documentation, and the most effective ways to manage records without burying the clinician in unwieldy paperwork. Docum ...
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Audits are a thing. Are you ready for one? That's the number one question my consulting clients have about their documentation. When records are audited for claims review, the number one thing the auditor is looking at is progress note structure. This podcast episode is about the discipline you need to think about when documenting. There are a lot …
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Part of the main information we need to be documenting in our progress notes is related to what we, the clinician, are doing in the therapy session. But what do we write down? What's important? What is not? One thing that is clear that we should be documenting is the interventions we're utilizing. But what are they really and how do they fit in? Th…
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As we think about the treatment journey with our clients, particularly as it relates to the idea of establishing the medical necessity of treatment, requires us to understand what is really going on. This episode discusses the importance of completing assessment as the important "first step" in treatment.…
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There's a lot of talk about how Couple's of Family Therapy aligns with the health insurance paradigm. It can be confusing to understand when it's appropriate to submit claims for these services and when it's outside of what the expectations are from the third-party payers. This episode focuses on this topic and how to determine when it might be app…
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How often should you update your treatment plan? It is a core question that many clinicians have related to this part of our clinical documentation. And of course, it comes with more than one answer. This podcast seeks to talk a bit about how to think about this process and setting up an internal system to consider the optimal ways of accomplishing…
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The Impact of Procrastination on Your Practice
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All of us, at some point in time in our lives, are impacted by Procrastination. There are parts of the behavioral health clinician's job that is based on getting things done "on time", and it can have a profound impact on us. This episode focuses on what procrastination is, what triggers it, and how we can defeat it.…
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If you run a practice group with multiple clinicians you know how challenging it can be to get your team to all pull in generally the same direction. Everyone has their own idea about how things should run. Having office policies and procedures can make a huge difference to the normal operations of your organization. This episode talks a bit about …
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A key part of creating an effective environment to optimize the effectiveness of psychotherapy is the creation an maintenance of a therapeutic environment that feels safe for the client. Feeling safe is a central part of building trust with the client, and establishes a place where the client can begin to feel comfortable in sharing the deeper part…
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We have all heard about SMART Goals. We may have even heard that we should use them to write up our treatment plans. But, really, what are they? And why are they important? This Podcast explores the power of the SMART Goal, why they are more about Objectives, and how they can help you drive your clinical connection with your clients.…
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As behavioral health clinicians we all know that we should complete an assessment before we start treating people. A complete biopsychosocial assessment can make the difference between success and failure in treatment. But really, why is it important? This Podcast explores the nature of the assessment process, why insurance companies (and everyone …
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Clinical documentation begins with an understanding of Medical Necessity. This episode focuses in on what Medical Necessity is and why its important, how we identify it, and an introduction to how we document it.By Steve
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