Mental health documentation is an essential aspect of psychotherapy sessions. Documentation helps mental health professionals track progress from session to session, bill insurance, and helps justify why the client is there. Many mental health clinicians like to follow a specified format for progress notes. Following a format helps ensure you’re meeting insurance requirements and enables you […]
In today’s fast-paced world, medical professionals are often inundated with a large amount of documentation that needs to be completed in a timely, smart, and secure manner. One of the ways to automate this process is by using HIPAA-compliant dictation software, which allows doctors, nurses, psychologists, therapists, and other healthcare professionals to dictate their notes in […]
If you’re a psychotherapist, you must document your psychotherapy sessions. One piece of the pie when you’re writing notes is being able to enter the interventions you have used in therapy. Sometimes, in talk therapy, it may feel like you aren’t doing much and the client is progressing. Knowing how to document your therapeutic interventions […]
If you’re a mental health professional, you may feel overwhelmed with all the different types of mental health notes. You might wonder what types of notes you have to write, what types of notes can be helpful to you, or what all the different acronyms in note templates stand for. Knowing that you’re providing sufficient […]
That incident still resonates in my head. I was in the elevator heading to my clinic when I got captivated by a poster hanging in the hallway: “Care not documented is care not purveyed.” I spent the whole day having a hard time deciphering the meaning behind it; until it popped up: if your services […]
Do you ever feel overwhelmed as a mental health professional when it comes to keeping up with therapy note-taking or transcribing the audio recordings of your therapy sessions? It’s a challenge nearly every clinician faces, no matter the approach they practice. Research shows that many therapists spend hours outside of sessions just managing paperwork, which […]
Mental health clinicians have to document all counseling sessions that they complete. Unfortunately, writing notes can be difficult for many clinicians and becomes a dreaded task. As a result, you may have questions about what formats to use or what should go into a note. In addition to different types of note formats, different types […]
Mentalyc and Note Designer are two of the popular tools used by therapists for note-taking and client management. Both tools offer features to help therapists keep track of their client’s progress and provide better care. Purpose of Comparing Mentalyc and Note Designer This article aims to compare Mentalyc and Note Designer in detail, highlighting the […]
What is GPT? OpenAI’s Generative Pretrained Transformer (GPT) is a cutting-edge language model that uses deep learning techniques to construct human-like dialogues, answer questions, write stories, and perform a variety of natural language processing tasks. GPT has an excellent capacity to recognize context and respond appropriately, resulting in extremely precise and polished output. The model is at […]
If you’re a mental health clinician, documenting client intake appointments is an essential first step that you will frequently encounter. A therapy intake occurs in the first appointment, where you gather background information about your client. The questions you ask in the first appointment with a new client help you understand the client’s presenting problems […]
Setting the Stage: What Is Couples Therapy? Think about your relationship with your partner. Is there a lack of intimacy? Do you find yourself struggling with everyday communication? Are there escalating conversations in which one or both of you become emotionally distressed? Have you noticed a lack of sexual connection? Well, if you said yes […]
If you’re looking for a problem-focused note format, consider writing PIRP notes to document your therapeutic sessions. PIRP notes are a method of clinical documentation used by many therapists and other mental health professionals. PIRP notes have four sections and are easy to write. So if you’re a mental health professional considering a new note […]
BIRP notes are a type of note format used by many mental health professionals. BIRP notes have four distinct sections so you can follow along and ensure your documentation is professional and up to standard. If you’ve tried other progress note formats and can’t get on board, you may consider trying a BIRP note. BIRP […]
GIRP Notes GIRP notes are a form of progress note documentation that mental health professionals can use to document their sessions. GIRP progress notes differ from some other common forms of documentation as they include a goal section in their format. These notes may be a good option for your practice, as they may help you keep […]
EMDR Notes: All Your Queries Answered! Have you ever found yourself scuffling with upsetting events that negatively impacted your life? You constantly find yourself making unwholesome decisions that you don’t understand, you probably struggle to get through your day, are exasperated by feelings of restlessness, and eventually end up tossing and turning all night long, […]
Mental health BIRP notes are an important part of the therapeutic process for mental health professionals. B.I.R.P. stands for “Behavioral, Intervention Response, and Plan,” and they are an integral part of the assessment, treatment, and follow-up of mental health clients. These notes are used to document patient progress, provide evidence for treatment decisions, and give […]
Documentation is a crucial part of mental health treatment in today’s age of accountability. It is the only evidence demonstrating the need and effects of treatment. Simply stating that a client has a certain diagnosis or claiming that therapy has been helpful to the client is an opinion but not evidence. Empirical evidence demonstrating that […]
Choosing software to use in your therapeutic practice requires a lot of consideration. It’s crucial to ensure the tool or platform you eventually pick will improve the efficiency of your practice. Mental health professionals need to keep in mind that note-taking and documentation are fundamental aspects of their profession. However, as important as it is, […]
The Cures Act (short for the 21st Century Cures Act) Psychotherapy Notes was signed into law in December 2016. Some of the sections of this law are more pertinent to the work of psychotherapy than others. We want to pay attention to aspects of the delivery of care, including information on leveraging electronic health records […]
As someone who’s worked on both sides of healthcare in the direct practice of psychotherapy as well as performing utilization management functions for healthcare organizations, I’m happy to provide some general guidance around the topics of medical necessity, insurance authorizations, and the relevance of documentation in supporting the clinical treatment needs of clients. Without further ado, let’s […]
Manual documentation can be a tedious and time-consuming task for therapists, but new technology is emerging that can make the process more efficient. As a therapist, you may need to spend a significant amount of time writing therapy progress notes and documenting patient information. It can be easy to fall into the habit of typing […]
Note-taking is an essential aspect of the therapy profession, but it can also be a significant source of stress for many therapists. This is particularly true for mental health professionals who see multiple clients every day and have to take detailed therapy progress notes at the end of each session for each client. It may […]
What is Medical Necessity? Medical necessity is the concept that a particular medical treatment or service is required to diagnose, treat or prevent a specific medical condition and that it is appropriate and acceptable according to generally accepted standards of medical practice. The idea is that medical treatments or services should only be provided if […]
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of patient health information. The law requires covered entities, such as health care providers and health plans, to take steps to safeguard this information. One way the law does this is by restricting the disclosure of psychotherapy notes. The psychotherapy […]
