Medically Necessary Documentation Introduction

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Medically Necessary Documentation Introduction by Mind Map: Medically Necessary Documentation Introduction

1. What is a personal strength when it comes to clinical documentation?

1.1. Finished in timely manner

1.2. keeping it concise while still being thorough

1.3. Being concise.

1.4. Using the 'golden thread'

1.5. finishing ontime

1.6. Being concise

1.7. Tying session and clients' goals together

1.8. getting them turned in the same day

1.9. time management

1.10. Completing concisely and quickly

1.11. Being brief when documenting.

1.12. Turning them in the day of session

1.13. Good vocab and clinical knowledge

2. What is something you struggle with when it comes to clinical documentation?

2.1. writing too much

2.2. Feeling overwhelmed with case notes and paperwork

2.3. feeling like i need to write everything the client said in session in the case note

2.4. Remembering what they said exactly

2.5. figuring out best language to use.

2.6. Finishing in a timely manner

2.7. Time management and burnout.

2.8. trying to be concise but also trying to remember details of the clients from session to session

2.9. Too much storytelling

2.10. not knowing how to compartmentalize what is medically necessary vs what I want to remember about session or something impactful client said

2.11. Trying to get the balance between clinical language and client understandings.

2.12. completing all documentation (sometimes feel like I am missing something)

2.13. Time management

2.14. Adding unnecessary information

2.15. trying to get the balance between client and clinical

2.16. Time management.

3. What is something you want to learn?

3.1. about better documentation

3.2. how to be more succinct in notes

3.3. To be more concise but thorough

3.4. How to write notes to cover all liabilities.

3.5. how to make it easier

3.6. what should I avoid or what are the most common/biggest pitfalls

3.7. how to include clients in the process/use their input to help them feel more engaged

3.8. Documentation

3.9. How to make notes more concise

3.10. How to cover all bases and stay on top of all documentation

3.11. How to be more concise and include the client

3.12. How to write better notes with proper details.

3.13. specific goal writing techniques

3.14. What is really needed in a note and what is not relevant.

3.15. figure out what is necessary to include

4. What is your level of understanding on the why we do documentation?

4.1. Somewhat understand

4.2. decent

4.3. minimal

4.4. To satisfy insurance companies

4.5. moderate understanding

4.6. minimal/moderate

4.7. Overall understanding

4.8. somewhat

4.9. I think I have a good understanding

4.10. a good understanding

4.11. decent

4.12. A good understanding.

4.13. Very good understanding