Mastering DSM-5® Differential Diagnosis, Mental Health Documentation & Medical Necessity- Beth Rontal & Margaret L. Bloom

Mastering DSM-5® Differential Diagnosis, Mental Health Documentation & Medical Necessity- Beth Rontal & Margaret L. Bloom

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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, LICSW, affectionally known as the Documentation Wizard. For over 15 years, Beth has been instrumental at changing how individuals and organizations 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.

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
Operationalize the presenting problem
Questions to ask
Describe the diagnostic criteria in behavioral 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

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