SOAP vs. DAP notes: Which should you use?
Here’s how to decide which progress note-taking style is right for you.
Sharpen up on compliance practices, including taking great notes and navigating insurance requirements.
Here’s how to decide which progress note-taking style is right for you.
Learn more about the ADNM-8 assessment and how you can incorporate it into your practice.
Learn more about the IES-R assessment and how you can incorporate it into your practice.
You can make writing the “objective” section of SOAP notes even easier.
These tips can help you stay focused.
Here are the documentation and notes requirements you’ll want to remember as a prescriber.
Administering assessments to diagnose and treat a client’s evolving symptoms can provide a picture of how your client is doing over time.
Biopsychosocial assessments allow therapists to understand the most important components affecting clients’ mental health symptoms.
Learn more about the ASRS assessment and how you can incorporate it into your practice.
Here's what you need to know to safeguard patient privacy and ensure the security of sensitive mental health information.
Learn more about the World Health Organization-Five Well-Being Index and how you can use it in your practice.
Learn more about the PCL-5 assessment and how you can incorporate it into your practice.
Here’s what you need to know about medical necessity — like how to make sure your 90837 and 99205 notes are compliant.
Learn more about the ISI assessment and how you can incorporate it into your practice.
EMR cloning may initially seem like a time-saving technique, but it poses serious risks.
Understanding why audits happen, and preparing for a potential audit of your client records, can help you set your best foot forward.
When it comes to family therapy and group therapy, progress notes can become more complex due to the multiple parties involved.
Every discharge situation is different, but a few best practices can help ensure the discharge note documentation process is successful.
The GAD-7 can help you narrow down a diagnosis if your client is experiencing anxiety symptoms, along with allowing you to track their progress over time.
The Patient Health Questionnaire-9 helps screen for, diagnose, and track progress with depression.
The “golden thread” helps connect the dots between your clinical and administrative work.
The BIRP note template focuses on how the client appears to think and feel before and after your therapeutic intervention.
Here’s how to write and structure DAP notes, plus DAP notes examples and templates to help guide you.
Progress notes are the core piece of documentation a mental health care provider should write after each session with a client, but it’s more than just a record of what happened in the session.
Whenever you want to change the goal of your therapy care, or the path you want to take with the client to reach that goal, you’ll want to document a treatment plan.
The intake assessment is your chance to get a deep understanding of your patient — and maybe connect some elements from their journey that they wouldn’t connect themselves.
Here’s how SOAP notes can help you write better, faster notes — and effectively document your work as a clinician.
Based on our conversations with insurers, here are 10 of the items most commonly missing from charting documentation, including examples of what it takes to meet the requirements for each.