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The majority of licensed clinical work has to do with choices. Its important for a recording such as an assessment or progress note be specific to treatment. First the clinical writer must accept the psychotherapy hypothesis of Medicare.
You Are Required To Accept Medicare’s Theory
Clinical Records Value Based Thinking
It is generally accepted that psychotherapy changes a person’s behavior when psychotherapy is professionally deployed by behavior modification, interacting supportively,problem solving, cognitive restructuring, explanation of thoughts, instruction of reality and socialization is clinically deployed in a purposeful manner. When doubtful consult your state license board statute.It’s no coincidence that Medicare policy is similar to these statute requirements.
Measuring the efficacy of your treatment is the clinicians responsibility and should be written in the writers recording. Instead, subjective, objective, assessment, treatment should be.To be sure many clinicians are expected to be confused at first and may be audited, feel challenged, and sometimes intimidated. I think these are normal feelings but in the end standards will be enforced. Compliance assured. Life goes on.
To make life better for the starting practice I’ve compiled Medicare guides on this page for you to develop a value based purchasing mind set. Value based purchasing has been with us for a long time if not as a coined phrase named value based purchasing. Whatever we call value based purchasing its just quality and fiscal controls.
Introduction
Psychotherapy Guide
Highmark Guide
Inpatient New Era
You may acceptably obscure certain clinical thoughts but not clinical recording of fact. To explain this specifically the following content is offered.
Integration Models