Improving and Simplifying Case Notes: Practical Strategies for Clinicians

Presented by Maelisa Hall, PsyD on 08-05-2016 at 9 a.m. Pacific (noon Eastern)

Many mental health professionals receive little or no training in documentation prior to starting their practice. However, writing case notes is a significant aspect of most clinicians' daily work. The lack of adequate training and support in the documentation process, coupled with most professionals' dislike for this task, often contributes to feelings of resentment, anxiety, and fear at the mere mention of “notes” or “records request.” However, thinking about notes from the perspective of those in treatment, who are often helped by clinical notes, can help clinicians see how writing notes can be a meaningful part of any therapy practice. 

In this two-hour interactive web conference, Dr. Maelisa Hall will cover essential strategies for writing high-quality case notes, review common pitfalls clinicians experience with documentation, and share realistic and helpful examples designed to replace any negative emotions surrounding documentation with confidence. Dr. Hall will highlight the importance of knowing the ethics requirements for documentation and share how to individualize and apply these concepts effectively in practice. In addition, this presentation will evaluate different options for note templates and outline strategies to simplify clinical notes and still meet ethical and insurance guidelines. Participants will be encouraged to ask questions and share real-life challenges they have experienced with clinical documentation during question-and-answer sessions.

This introductory instructional level course is designed to help clinicians:

  1. Identify an individualized notes template that applies to clinical practice.
  2. Outline the components of a progress note incorporating applicable ethical guidelines.
  3. List the most common risks associated with clinical documentation.
  4. Identify how medical necessity may impact notes for insurance.
  5. Describe at least three strategies for writing case notes more efficiently and effectively.
  6. Evaluate client case notes objectively from intake to termination.

If you have any questions or concerns about this web conference or would like more information, please contact us here.

How the Web Conference Works

Attendees who register for this event will log in to the web conference center by using a computer and calling in to the teleconference line. Attendees will be able to ask live audio questions via phone and/or submit text chat questions via computer. Live streaming video and/or document sharing will also be available to participants. Alternatively, attendees may dial in to the teleconference line only, though attendees dialing in by phone only will be unable to ask questions. Attendees may also access the web conference on a smartphone or tablet. 

Before the scheduled event, all registered attendees will be sent a reminder email with specific instructions on how to log in to the web conference center, as well as links to optional handout materials if applicable.

At the conclusion of this event, you will receive an email with information about how to request a CE certificate. You will need to enter the start and end codes that will be announced at the beginning and end of the presentation. These codes confirm that you attended the entire event. You will be prompted to complete a survey. You will need to complete this online survey within six days of the event. Once you complete the survey, you can download a copy of your CE certificate instantly.

388CE hours and counting!

All are available to GoodTherapy.org members at no additional cost.

Continuing Education (CE) Information

Two CE credits will be provided by GoodTherapy.org for attending this web conference in its entirety.

GoodTherapy.org is an Approved Education Provider by NAADAC, The Association for Addiction Professionals (provider #135463). Of the eight counselor skill groups ascribed to by NAADAC, this course is classified within documentation and legal, ethical, and professional development.

GoodTherapy.org has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6380. Programs that do not qualify for NBCC credit are clearly identified. GoodTherapy.org is solely responsible for all aspects of the programs.

This organization, GoodTherapy.org, provider #1352, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) program. GoodTherapy.org maintains responsibility for the program. ASWB Approval Period: March 30, 2016 through March 30, 2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. Social workers participating in this course will receive two clinical continuing education clock hours.

GoodTherapy.org is approved by the American Psychological Association to sponsor continuing education for psychologists. GoodTherapy.org maintains responsibility for this program and its content and is solely responsible for all aspects of the program.

GoodTherapy.org, SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0395.

Registration Information

This web conference is available at no cost to GoodTherapy.org members.

This event has already taken place. An audio recording for this event may be available in the Member's Area.

Event Reviews from Members

Everything was excellent.  As someone who has been away from the field for a time, and is returning, I found all of it extremely helpful. - Monica Bowen, LPC

Meet the Presenter

Maelisa Hall, PsyD

Maelisa Hall, PsyD

Maelisa Hall, PsyD is a licensed clinical psychologist living in Long Beach, California. She currently serves as the Quality Assurance (QA) Director for a state-contracted mental health program and is the owner of QA Prep, where she offers online trainings and clinical consultation in documentation for mental health professionals.  

Training is Dr. Hall’s true passion, and she loves to help therapists connect meaning to the typically mundane task of paperwork. After years working in quality improvement, she has noted that confusion, anxiety, and resentment related to documentation are all too common for clinicians. Her experience has shown her most professionals care deeply about their work and find documentation much easier when they are able to identify and understand how paperwork actually helps the people they work with in therapy.

Dr. Hall provides online training programs for therapists in private practice and consultation for agencies and individual practitioners. She also travels as a speaker and trainer and presents on the topics of improving documentation and ethics. She maintains an active blog and provides free monthly trainings for therapists through her website, www.qaprep.com.

  • ace
    GoodTherapy.org is Approved by the American Psychological Association to sponsor continuing education for psychologists. GoodTherapy.org maintains responsibility for this program and its content. APA approval applies to all events listed after May 2011.
  • Logo
    GoodTherapy.org has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6380. Programs that do not qualify for NBCC credit are clearly identified. GoodTherapy.org is solely responsible for all aspects of the programs.
  • Logo
    This course has been approved by GoodTherapy.org, as a NAADAC Approved Education Provider, for educational credits. NAADAC Provider #135463. GoodTherapy.org is responsible for all aspects of their programming.
  • ace
    GoodTherapy.org, provider #1352, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. GoodTherapy.org maintains responsibility for the program. ASWB Approval Period: 03/30/2016 – 03/30/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. Social workers participating in this course will receive 2 clinical continuing education clock hours.
  • GoodTherapy.org, SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0395.