About this course

Learning Objectives

• Determine how to translate clinical skill and intuition into the behavioral language required for mental health documentation.
• Name 1 question to ask the client to co-create a treatment plan.
• Employ the Golden Thread in treatment planning to help justify medical necessity.

Learning Levels

• All Levels

Target Audience

Course Instructor(s)

• 

  Beth Rontal, LICSW

  Beth Rontal, LICSW, is a nationally recognized and engaging speaker on mental health documentation for private practice clinicians and those working in agency behavioral health settings. Her Misery and Mastery SM trainings and accompanying forms have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years.

  Beth was instrumental in developing the clinic’s first electronic documentation system that significantly reduced documentation time and errors. After the implementation of this system, the transformation from error laden to accurate record keeping saved the clinic thousands of dollars, reduced time spent writing notes, which enabled clinicians to see more clients without spending more time working.

  Beth’s Documentation Wizard® training program empowers clinicians, reduces anxiety about documentation, and furthers professional integrity. It simplifies the documentation process by systematically linking effective documentation to quality care. This helps to pass audits and protect income.

  Beth writes blogs on clinical documentation, co-chairs the NASW Private Practice Shared Interest Group, and has a private practice in Brookline, MA specializing in working with people who struggle with emotional eating. Her other interests include writing and performing cabarets and her current one-woman show called, “My Mother’s Daughter.”

Disclosure

References

• Baker, Shanfield, and Schnee (2000). Using Quality Improvement Teams to Improve Documentation in Records at Community Mental Health Center. Retrieved from URL https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.51.2.239.
• Center for Medicare Medicaid. (Dec. 2019) Improving the Medicare Claims Review Process. Retrieved from URL https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/What_Is_TPE-Infosheet.pdf
• Matthews, E. B. (2020). Computer use in mental health treatment: Understanding collaborative documentation and its effect on the therapeutic alliance. Psychotherapy, 57(2), 119.
• MLN Booklet. Center for Medicare & Medicaid Services (2021). Medicare Fraud & Abuse: Prevent Detect, Report Retrieved from URL: https://www.cms.gov/.../Downloads/Fraud-Abuse-MLN4649244.pdf
• Open Notes R, (2020). Federal Rules on Interoperability and Information Blocking, and Open Notes. Retrieved from URL https://www.opennotes.org/onc-federal-rule-interoperabilty-information-blocking-and-open-notes/
• Denneson, L. M., Chen, J. I., Pisciotta, M., Tuepker, A., & Dobscha, S. K. (2018). Patients’ positive and negative responses to reading mental health clinical notes online. Psychiatric Services, 69(5), 593-596.
• Pisciotta, M., Denneson, L. M., Williams, H. B., Woods, S., Tuepker, A., & Dobscha, S. K. (2019). Providing mental health care in the context of online mental health notes: advice from patients and mental health clinicians. Journal of mental health, 28(1), 64-70.