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 […]
There is a growing interest in using artificial intelligence (AI) in therapy and mental healthcare nowadays, both on the therapist’s and the client’s sides. We hear a lot about clients going for AI therapy using chatbots instead of going to a therapist for therapy, especially after the pandemic, to get a cure for their mental […]
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 […]
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 […]
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, […]
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 […]
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 […]
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 […]
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 […]
Being a therapist can be a demanding job, requiring long hours of sessions, followed by an even longer process of writing progress notes. However, Thomas Hanna (LMHC, NCC, CCTP, CCATP), a licensed therapist from Tempest Counseling in Tampa, Florida, found a way to streamline his note-taking process, freeing up time and energy to focus on his clients. The […]
If you’re a business owner or practitioner delivering outpatient psychotherapy or counseling services, you’re probably well-versed in the arena of health insurance. At the very least, you understand that whether the setting is a hospital system, community clinic, or private practice – we depend on insurance reimbursement to survive financially. If you choose not to […]
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 […]
As a therapist, it is common to seek out methods for creating notes that do not require manual writing. There are many different tools available on the market that can aid in the note-taking process for therapists. These tools can range from typing time-reducing, customizable templates, to software that fully automates the note-taking process and […]
Mental health records are generally protected by state and federal privacy laws. These laws vary from state to state, but they typically provide that mental health records can only be released with the patient’s consent. In some cases, such as in an emergency, mental health records may be released without the patient’s consent. State and […]
Should I Take Notes During Therapy? There’s no simple “yay or nay” answer to taking notes during therapy. In this blog, we’ll discuss the very real and practical pros and cons of note-taking for practitioners of professional psychotherapy or counseling services. We should begin this discussion by acknowledging that our healers go by various titles – […]
As a psychotherapist, you understand that accurate and thorough notes are essential to provide great patient care. But did you know that there are specific requirements for how you must document your patients’ mental health information if you accept Medicare? To be compliant with Medicare regulations, your psychotherapy notes must include certain elements related to […]
As a therapist, you know that documentation is an essential part of your job. Not only do you need to keep track of your client’s progress, but you also need to make sure that your documentation is compliant with payer and insurance requirements. Unfortunately, this can be easier said than done. It can be a […]
Almost every therapist takes notes from their sessions. More often than not, trying to capture everything you discussed with your client from the session may get stressful. Tools like Simple Practice and Mentalyc are designed to help you make your note-taking easier and more intuitive. Both of them can make your psychotherapy easier and less […]
It’s no secret that therapists have to take careful notes during sessions with patients. But did you know that those notes are subject to the same federal privacy laws as other medical records? To protect the confidentiality of their patients, therapists must take care to write their psychotherapy notes in a HIPAA-compliant manner. That’s right: […]
As the young patient stepped out of the elevator into the clinic, you greeted her warmly, immediately recognizing her and welcoming her in while inquiring about her whereabouts. It was only two minutes in when the patient began to feel the unique client-therapist connection and ushered in an intimate talk where their deepest feelings and […]
