"The Art of the Progress Notes: Where Law & Ethics Meets Efficiency"
Presenter: Elizabeth P. Irias, MS, LMFT
2 CE Hours
All Learning Levels
Don’t wind up in the back of The Therapist because of preventable documentation problems. Many myths, such as “Write vague notes in case the notes are used in court” and “Private pay therapists don’t need to keep notes,” float around our profession. These mistruths contribute to documentation mistakes that can have significant consequences for clinicians and clients alike. This presentation will increase your understanding of the legal and ethical factors that impact documentation regardless of pay source (insurance, cash, etc.) or workplace (agency, private, etc.). Attendees will learn how to conceptualize Medical Necessity and integrate it efficiently into clinical documentation.
This presentation offers key information about clinical documentation-related laws and standards of care that are often unknown to clinicians, and is designed to sharpen the clinical documentation skills of providers, thereby reducing liability risks and improving the quality of client care. Therapists are told time and time again that their notes are legal documents, yet they often receive very little training about what actually needs to be in them. Further, misunderstandings about the legal and ethical requirements for clinical documentation contribute to therapists making inadvertent errors that can have significant consequences for them and for their clients. Clients have lost benefits such as short-term disability and insurance-treatment authorizations because of clinical documentation oversights, and clinicians are at risk of licensure loss, criminal investigation, and medical negligence charges if their clinical documentation is inadequate. The goal of this seminar is to provide clinicians with succinct, clear guidance to clear up misunderstandings and improve overall clinical documentation quality.
Upon conclusion of this workshop, participants will be able to:
- List three legal or ethical implications of inadequate clinical documentation practices.
- Identify five important components of quality clinical documentation as they relate to Best Practice.
- Provide a general definition of Medical Necessity as related to clinical documentation.
Elizabeth P. Irias, MS, LMFT, is the founder and president of Clearly Clinical, an affordable national podcast Continuing Education company. Known as the “Utilization Review Guru,” she has specializations in Utilization Review, Clinical Best Practice, and Clinical Documentation, and works closely with clinical teams across the country to improve their quality of care, documentation practices, and Utilization Review outcomes. An adjunct graduate professor at Pepperdine University, Beth is an engaging professional conference speaker known for her tongue-in-cheek style. She operates a private practice in Westlake Village, CA, where she treats adolescents and young adults, members of the LGBTQ+ community, and those with addictive disorders.