For Consult Monday, we discuss,

• How to follow the rules without spending all day on notes
• Pick the central theme for the session and focus on that but include anything that feels clinically relevant.

Too Much Notation VS Too Little:

• New clinicians usually get OTJ training regarding clinical documentation. Some agencies may want a lot, some agencies may want bare-bones style notes. When documenting, keep in mind the best interest of your clients if there are any lifestyle issues or specific life events that may come up again in therapy.

Clinical Relevance:

• Document information if it’s relevant to their reason for the visit.
• Think about your phrasing: is it respectful and nonjudgmental? Is it empathetic?

Check out Maelisa's FREE Private Practice Paperwork Crash Course