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Free CEU: Clinical Documentation – What You Need and What You Don’t.

Free CEU: Clinical Documentation – What You Need and What You Don’t.

posted by: Nicole Hovey date: May 29, 2019 category: Blog comments: Comments Off on Free CEU: Clinical Documentation – What You Need and What You Don’t.

“I was taught to keep my notes vague.”

I hear this all the time… I was taught exactly the same thing! I hear this one, too: “If you don’t accept insurance, your notes don’t really matter.” One of my favorite professors, an expert on meditation and expert witness appearances, emphatically told my class, “You never know when your notes could be used against a client, so always keep them short and general.” It sounded good to me… except for the fact that he was wrong… short and general notes are a recipe for disaster from a liability standpoint. (And I have a funny anecdote to share about that professor, but more on that later…).

So many myths float around our profession, and they’re sometimes very dangerous for us and for our clients. Our notes, regardless of whether we’re in private practice or at an agency, are legal documents, and they need to reflect the same accuracy and detail expected of medical professionals. Yes, my previous professor was right about part of it: Our notes can be used in court, and they may be detrimental to a client. That said, they can also be used to protect us in the event of a sentinel incident investigation, like a suicide, or if there’s a complaint filed against our licenses. Our notes can also help our clients receive the care and benefits they need, like short-term/long-term disability or insurance authorizations. We are in a line of work that is inherently unpredictable, and the care we provide can be risky… our notes need to illustrate why we did what we did, at every step of the way.

What’s more, our notes need to consistently establish and illustrate medical necessity, even if we don’t accept insurance. I like to draw upon the medical model to illustrate this point: Imagine a surgeon performing a surgery and failing to keep notes of what she’d done because the patient asked her not to? Imagine if she didn’t keep notes because the patient paid cash instead of using insurance? Imagine if she performed the surgery and there was a complication, and the patient filed a board complaint against the doctor? It’s a real slippery slope. Oftentimes, the only thing standing between us and licensure loss is our records. Additionally, did you know that therapists can even be faced with legal charges like insurance fraud or medical negligence for failure to keep appropriate records? Eek! And double eek when you consider that a medical negligence charge has nothing to do with whether or not a clinician accepted insurance payments!

So, given that I heard these myths too many times, I created a free podcast Continuing Ed course on the subject, called Clinical Documentation: What You Need & What You Don’t approved by the APA, NBCC, NAADAC, CAMFT, and CCAPP. We clinicians didn’t go into this line of, work because we like keeping records, but they’re very important to our clients and to our practices, and this free course is my little way of trying to guide clinicians away from preventable documentation oversights.

And back to the story about my professor: Years later, said professor came to see one of my clinical documentation trainings. When I went to speak with him afterwards, his voice was a little shaky, his face a tad bit pale. He sheepishly said, “Oh my. I had no idea. The student surpasses the master.” I laughed, patted him on the back, and assured him that I’d help him get his notes in order…!


About the author: Elizabeth (Beth) Irias is a Licensed Marriage & Family Therapist with a specialization in Law & Ethics, and the founder of Clearly Clinical, a podcast-based Continuing Ed company approved by the APA, NBCC, NAADAC, CAMFT, and CCAPP. It’s Clearly Clinical’s mission help clinicians learn, grow, and shine by way of high quality, affordable, diverse, and relevant podcast Continuing Education courses. Clearly Clinical donates a portion of proceeds to The Trevor Project in support of suicide prevention services for LGBTQ+ youth, and regularly offers free and low-cost live and online Continuing Education courses. It’s time to shine a new light on Continuing Ed. Please visit to learn more!

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