Description
Mental health therapists write progress notes every day of their career, yet many clinicians receive little or no training on this topic. They try to use vague ethical guidelines, legalese, and hearsay from office colleagues to determine the answer to an all-important question: What goes in a progress note?
They do this knowing that documentation is the key to justifying medical necessity, which is necessary for counseling clients who use insurance, and often determines whether or not a therapist gets paid.
In short, clinical documentation becomes a significant stressor for many mental health professionals.
Stress Free Documentation for Mental Health Therapists provides quick and easy to use templates, practical advice for saving time on administrative tasks, and research-backed recommendations. Part workbook with templates and part guidebook, readers gain access to reference material that is curated specifically for mental health clinicians in a variety of settings – private practice, clinical supervision, and internship or practicum.
This book will not only show you what to write in your mental health paperwork, it will teach you how to think about documentation so you can make informed decisions on your own. Filled with ready-to-use worksheets, quizzes, and clear action items, every mental health therapist can use this book as a daily tool to support their clinical work.
Stress-Free Documentation for Mental Health Therapists also meets continuing education and accreditation criteria for graduate schools and professional associations, meeting the documentation needs of clinical professionals and graduate students alike. Professors can find guidance for all professions to meet the needs of graduate students in counseling, psychology, marriage and family therapy, and social work.
Start your stress-free documentation journey today!
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kay9222 –
I was given a promotional copy of this book, yet I also pre-ordered a copy as well to keep on my Kindle. This book is awesome!! These are my own personal thoughts without input from anyone else.
I love this book for several reasons. I like how each chapter flows into the next so naturally and how there is no doubt about the point being made in each chapter. As someone recovering from difficult hand surgery and grafting, the templates in the book are such a gift as I don’t have to type as much. As I also struggle with ADHD, this simplifies my work!!
I find the book full of encouragement and warmth and anyone challenged with documentation needs this positive regard.
I think this book would be so useful in the hands of grad school professors, supervisors, practice managers in group practices and individuals in private practice.
This work is a game-changer for me. This book is something we all need to have on our shelves!!
East Coast LMFT –
Dr. McCaffrey has always taken a supportive stance about documentation. She knows that clinicians from all backgrounds and years of experience struggle with keeping up with notes, and even doubt they know what they need to include in notes. There is no shaming in her book, and she shares, “You are not a bad clinician if you struggle with documentation.”
Graduate school was a long time ago, but even then, we weren’t taught what needed to be in notes. It focused more on what we *probably shouldn’t put in our notes* and included way too much narrative of the things discussed in the session. After 15 years of being private pay (i.e. cash) in private practice, this year I’ve relied a lot on my courses from Dr. McCaffrey as I’ve transitioned to an insurance practice. I’ve heard horror stories over the years about dealing with insurance companies, and Dr. McCaffrey has so much wisdom to offer on documentation, not just based on her years of experience teaching supervisors, students, and clinicians, and working in quality assurance for local and state agencies. She knows what insurance companies look for when they audit your documentation, and how to make it a learning experience.
This book breaks down essential documentation topics in an easy format, making it easy to find quotes, info, and details in seconds. There are sample forms included, and a link to gain access to printable copies when you purchase the book. Peppered throughout the book are “Top Tips” and quotes that I found to be uplifting.
If you have ever struggled to write notes without writing and re-writing things, spent time looking for yet another template that promises to be better than the last, or found yourself struggling to keep up with your notes because you felt like you needed to include every single detail- you’ll want to get a copy of this book ASAP. It will not only take away your fear, but it will give you peace and calm about what to write along with a plan on when and how to do it.
*Disclosure: I’ve followed Dr. McCaffrey for several years now, and purchased her documentation forms package and documentation course a few years ago. I have been eagerly waiting for this book so I can keep it as a printed reference by my computer. I signed up on her website to receive updates about the book, and received an advanced digital copy of the book to read. I have purchased my own physical copy of the book. All opinions expressed in this review are my honest thoughts.
Lisa Gillispie, LPC, SEP –
I was fortunate enough to receive an advance copy of this book. I have spent so much money and time trying to crack the code of documentation so I could feel confident and competent with it. I wish I had had this book during my internship or first year in private practice. I would have saved a TON of time and money and alleviated a lot of stress. I don’t bill insurance, but I do have some clients who request a superbill, and regardless, I want to have my documentation ducks in a row.
Maelisa has such a compassionate and understanding tone throughout this book. The first chapter guides you through what sections to prioritize based on your specific needs. The section outlining what Maelissa calls the “clinical loop of documentation” was invaluable for helping me understand how the different aspects of documentation interweave and come together. Finally, charting makes sense beyond keeping track of what happens from session to session!
I love the clinician spotlights that highlight real life examples and suggestions. The templates are also incredibly helpful. I finally feel confident about my documentation! I’m clear on what I need to do to document in a way that meets my ethical obligation as a clinician and best serves my clients. I’ve used the templates to streamline my documentation process and shorten the time I spend keeping up with my charting. I can’t recommend this book highly enough!