What’s Missing From Your Client Charts: Writing Great Progress Notes

Presenter: Barbara Griswold, LMFT

While you may shiver at the idea of an insurance plan, ethics committee, or licensing board reviewing a client chart, this is happening more frequently, even if you don't work with insurance. In these cases, well-written records can be your best defense, or can assist your clients in getting needed treatment or disability approval. But if you are like most therapists, you never received training in how to write progress notes. And you may not realize how your current note-keeping habits can hurt you – and your clients. This webinar will teach you how to write notes that will meet legal, ethical, and insurance plan expectations, so that you can feel confident if you ever receive a records request. You will learn about documentation requirements in case you are audited or your treatment is reviewed, and be introduced to several common note templates. Best of all, you’ll get the rare opportunity to see examples of what your progress notes should look and sound like. More detailed notes can mean protecting ourselves, as well as helping clients get the treatment they deserve.

Learning Objectives:

After this webinar, attendees will be able to:

1. Identify how superficial, vague, or unreadable notes can harm therapists and clients
2. Identify what health plans require in an intake note and progress notes
3. List the key elements of an excellent progress note
4. Give a general definition of “medical necessity,” the criteria health plans use to approve care

Barbara Griswold, LMFT, is a private practice coach and author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should, now out in its seventh edition. In private practice in San Jose, California, her passion is teaching therapists about the business essentials of maintaining a thriving practice. She’s been interviewed on National Public Radio’s “Morning Edition," and written articles for Psychotherapy Networker and The Therapist magazines. She is a past member of the California Association of Marriage and Family Therapists’ Ethics Committee, and a former California Board of Behavioral Sciences examiner. She invites you to subscribe to her email newsletter and contact her with your insurance questions at www.theinsurancemaze.com.