On the Record: Progress Notes and Recordkeeping in Clinical Practice



Presented and developed by Frances Schopick, JD, MSW, LICSW


This two-day interactive workshop will examine best practices for record keeping in clinical practice. Day One will provide participants with a comprehensive overview of the legal as well as ethical requirements of health care records. Day Two will provide participants will a comprehensive overview of the practical application of information learned in Day One. 

Attendees may choose to attend one or both days. Day Two builds on what is learned in Day One. In all, attendees will come away with an understanding of how records can be applied to clinical practice and risk management.

 

Day One: Goals and Objectives

1.    To provide a comprehensive overview of the legal requirements of disclosure and informed consent, discussing purpose, function, and utility.  Attendees should come away with a clear understanding of what is required, such that they can review and edit their own disclosure statement, and ensure it is in compliance.

2.    To provide a comprehensive overview of the legal and ethical limits to confidentiality. Attendees should come away with a clear understanding of when disclosure may or must be made without client authorization

3.    To provide a comprehensive overview of the legal requirements and ethical relevance of health care records, as well as differing philosophies about what to record.  Attendees should come away with a clear understanding of how they can best comply with the law and also protect themselves and their practice and still render the best care and service they can. 

4.    To provide a comprehensive overview of the legal requirements and ethical concerns related to disclosure to third parties. Attendees should come away with a clear understanding of the legal and ethical issues involved in the release information to third parties, and how review their own forms for compliance.

5.    To provide a comprehensive overview of the legal and ethical issues of documentation of protected health information to third party payors. Attendees should come away with a clear understanding of how to comply with disclosure, as well as how to maintain client confidentiality to the fullest extent possible.

6.    To provide a comprehensive overview of development and use of treatment plans. Attendees should come away with a clear understanding of how to compose a treatment plan that is symptom-based and meets criteria for medical necessity.

Day Two: Goals and Objectives

1.  To provide an experiential format for writing disclosure forms that are tailored to the participant’s practice. Attendees should come away with a clear understanding of how to implement compliance rules taught in the first day of the workshop, including how to address new standards of Duty to Protect.

2.    To provide an interactive format for participants to understand how recordkeeping violations may result in DOH complaints. Attendees will study DOH documents and, in so doing, come away with a clear understanding of how to spot red flags that can be problematic later.

3.    To provide an experiential format for writing treatment plans. Attendees will gain an understanding of the documentation of symptoms and problems, and how to apply them to measureable goals and objectives for treatment plans. Attendees should come away with an understanding of how to reference symptoms, diagnosis, and medical necessity for optimal documentation of treatment.

4.    To provide an experiential format for writing progress notes. Attendees will come away with an understanding of language that best serves their practice in documenting counseling sessions. Participants will also gain understanding of how to make choices among different progress formats to determine what best suits their practice needs.

5.    To provide an experiential format for writing psychotherapy notes. Attendees should come away with a clear understanding of the difference between progress notes and psychotherapy notes, as well as choices participants may make if they choose to take psychotherapy notes.

6.    To provide an experiential format for writing mental status exams. Attendees should come away with a clear understanding of how to document client’s observable behavior. Attendees will gain an understanding of how cultural norms may interfere with observation, and how to avoid implicit bias in diagnosis.

 




Continuing Education (CE) Information


12 CEs

6 Law and Ethics CEs


Frances Schopick, JD, MSW, LICSW


Frances Schopick, JD, MSW, is an attorney with a background in Social Work and psychiatric research. She worked for nearly 20 years as a mental health diagnostician and clinician in agency, research and private practice.  Living in Seattle, she is on the Adjunct Faculty of the Icahn School of Medicine at Mount Sinai in the Departments of Psychiatry and Preventive Medicine, and was formerly on the Faculty of Harvard Medical School in the Department of Psychiatry.  Research publications, abstracts, and presentations reflect her work in Mood and Personality Disorders including Narcissism and Psychopathy. 

Now an attorney, Fran works with mental health provider DOH Licensees of all disciplines who have received subpoenas, have to testify, or who have DOH complaints against them.  She also provides consultation on ethical and practice clallenges that put counselors at risk for DOH Complaints.  She completed her BA at Barnard College at Columbia University in New York City, a Master's Degree in Social Work (MSW) at the Hunter College School of Social Work in MYC and a Juris Doctor (JD) at the University of New Hampshire.  She holds Washington State licensure as both an attorney and LICSW. 




Upcoming Dates and Registration


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