Blog
How to Document Motivational Interviewing (MI) Sessions
A practical guide for therapists, counselors, and social workers on documenting MI sessions accurately. Covers the PACE spirit, DARN-CAT change talk labeling, sustain talk documentation, OARS skills, readiness rulers, decisional balance, SOAP and DAP format adaptation, and what MITI fidelity reviewers look for.
How to Document Occupational Therapy Evaluations and Progress Reports
A practical guide for occupational therapists on documenting initial evaluations, treatment plans, progress reports, and discharge summaries. Covers insurance reimbursement requirements for Medicare, Medicaid, and private payers, how to write measurable functional goals, what the CMS 2026 changes mean for OT documentation, and how to handle school-based vs outpatient vs home health differences.
How to Document Occupational Therapy in Home Health and Early Intervention Settings
A practical guide for occupational therapists on documenting home health and early intervention visits. Covers OASIS requirements, IFSP documentation, caregiver training notes, environmental context, fall risk, functional goal writing for the home, and SOAP format adaptations.
How to Document Pediatric Occupational Therapy and Sensory Processing Sessions
A practical guide for pediatric OTs on documenting initial evaluations, sensory processing sessions, sensory diets, IEP goals, school vs. clinic records, Ayres Sensory Integration fidelity, billing CPT codes, and progress reporting.
How to Document Recreational Therapy and Therapeutic Recreation Sessions
A practical documentation guide for Certified Therapeutic Recreation Specialists (CTRS) covering leisure assessments, functional outcome tracking, activity analysis, group recreational therapy notes, and how to connect RT goals to the broader treatment plan.
How to Document Rehabilitation Counseling and Disability Services
A practical guide for rehabilitation counselors, vocational specialists, and disability services professionals on documenting IPEs, vocational assessments, functional capacity, VR progress notes, accommodation requests, and ADA compliance records.
How to Document Response to Intervention (RTI) and MTSS Frameworks
A practical guide for teachers, school psychologists, reading specialists, and intervention coordinators on documenting every tier of RTI and MTSS. Covers universal screening, Tier 1 through Tier 3 intervention logs, progress monitoring data, decision rules for tier movement, parent notification, and how RTI documentation feeds into special education eligibility determinations.
How to Document School-Based Counseling and Mental Health Services
A practical guide for school counselors, school psychologists, and school social workers on documenting counseling sessions, behavioral interventions, and mental health services in K-12 settings. Covers the FERPA vs HIPAA distinction, education records vs sole-possession notes, 504 and IEP-related documentation, mandated reporting, crisis response, and parent communication.
How to Document School Counseling Sessions and Student Support Plans
A practical guide for K-12 school counselors on documenting individual and group counseling sessions, student support plans, crisis response, 504 coordination, and parent communication within the ASCA framework.
How to Document Section 504 Plans and Accommodation Reviews
A practical guide for school counselors, 504 coordinators, and educators on documenting Section 504 plans, annual reviews, and accommodation tracking with compliance in mind.
How to Document Speech-Language Pathology IEP Goals and School-Based Services
A practical guide for school-based speech-language pathologists on documenting IEP goals, progress monitoring, and service delivery. Covers IDEA compliance, writing measurable goals with benchmarks, progress reporting formats, Medicaid billing documentation, and common documentation errors that lead to audit findings across large SLP caseloads.
How to Document Student Accommodations
Learn how to properly document student accommodations for IEPs and 504 plans. Covers selection, implementation tracking, and compliance requirements.