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Compliance & documentation

Sharpen up on compliance practices, including taking great notes and navigating insurance requirements.

Using measurement-based care in therapy

Administering assessments to diagnose and treat a client’s evolving symptoms can provide a picture of how your client is doing over time.

Using measurement-based care in therapy

What is a biopsychosocial assessment?

Biopsychosocial assessments allow therapists to understand the most important components affecting clients’ mental health symptoms.

What is a biopsychosocial assessment?

Preparing for a chart audit

Understanding why audits happen, and preparing for a potential audit of your client records, can help you set your best foot forward.

Preparing for a chart audit

How to use the GAD-7 for anxiety assessment

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.

How to use the GAD-7 for anxiety assessment

How to write BIRP notes

The BIRP note template focuses on how the client appears to think and feel before and after your therapeutic intervention.

How to write BIRP notes

How to write DAP notes

Here’s how to write and structure DAP notes, plus DAP notes examples and templates to help guide you.

How to write DAP notes

How to write progress notes

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.

How to write progress notes

How to write a mental health treatment plan

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.

How to write a mental health treatment plan

What are therapy intake assessments?

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.

What are therapy intake assessments?

How to write SOAP notes

Here’s how SOAP notes can help you write better, faster notes — and effectively document your work as a clinician.

How to write SOAP notes

10 insurer requirements commonly missing from notes

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.

10 insurer requirements commonly missing from notes