Documenting psychotherapy is done to summarize services provided to many audiences who have access including clients, payors, and potential legal situations that may occur. It is necessary for professional, legal, and ethical standards. Since psychotherapy is covered by medical insurance, the gold standard for documentation is now based on the need to satisfy insurance company requirements. The most rigorous standards for clinical documentation are Federal, which is why most third-party payors base their requirements on Medicare standards. That standard involves justifying the need for services conceptualized as “medical necessity.” A fundamental feature of medical necessity is part of a “Golden Thread.” When the Golden Thread is employed, each element of the therapeutic process is clearly documented so that the connection between all aspects of clinical work flows logically within each document and from one document to the other. The criteria for a client needing services and the Golden Thread work together to justify medical necessity. Best practice documentation includes the clinician’s voice in a succinct narrative that makes clear how they conceptualize the treatment while also utilizing templates to facilitate ease of documenting what is needed.

Hosted by Therapy Training Boston online and in Waltham, MA for 6 CEs. For more info, visit the event webpage.