Blog
How to Document Dermatology Visits and Skin Examination Findings
A practical guide for dermatologists, dermatology PAs/NPs, and medical assistants on documenting skin examinations, lesion descriptions, biopsy and procedure notes, photographic documentation, and using structured templates to reduce errors in derm-specific notes.
How to Document Dialectical Behavior Therapy (DBT) Sessions
A practical guide for DBT therapists on documenting individual therapy, skills group, diary cards, chain analysis, behavioral targets, consultation team notes, and phone coaching contacts without reducing the treatment to a checklist.
How to Document Dietetics and Nutrition Counseling Sessions
A comprehensive guide for registered dietitians and nutritionists on documenting nutrition counseling sessions. Covers the ADIME note format, medical nutrition therapy documentation for insurance reimbursement, initial nutrition assessments, follow-up visit notes, group education sessions, and the most common documentation mistakes dietitians make.
How to Document Domestic Violence and Intimate Partner Violence Cases
A comprehensive guide for social workers, therapists, and case managers on documenting IPV and DV cases. Covers safety-first principles, subpoena risk, mandated reporting, danger assessments, and how to write records that protect both clinician and survivor.
How to Document Early Childhood Assessments and Pre-K Progress Reports
A practical guide for Pre-K teachers, early childhood educators, and developmental specialists on documenting developmental milestone assessments, kindergarten readiness evaluations, portfolio-based documentation, family communication reports, and Head Start compliance.
How to Document Eating Disorder Treatment Sessions
A practical guide for clinicians treating eating disorders on how to document sessions involving medical monitoring, weight tracking, meal plan coordination, body image work, level of care decisions, and multidisciplinary team communication.
How to Document Elder Abuse and Adult Protective Services Investigations
A comprehensive guide for social workers, APS investigators, and case managers on defensible, audit-ready elder abuse documentation. Covers intake, investigation, evidence, interviews, risk assessment, safety planning, and court-ready records.
How to Document EMDR Therapy Sessions
A practical guide for EMDR-trained therapists on what to capture at each phase of the 8-phase protocol, how to document SUD and VOC ratings, bilateral stimulation parameters, target memory tracking, and between-session observations that satisfy insurance reviewers without over-documenting trauma content.
How to Document Emergency Department Patient Encounters and Triage Assessments
A practical guide for ED physicians, PAs, NPs, and nurses on documenting emergency department encounters. Covers ESI triage levels, chief complaint capture, medical decision-making for E/M coding, critical care time, procedures and results, disposition decisions, AMA discharges, and psychiatric emergency holds, with a focus on billing accuracy and malpractice defense.
How to Document Employee Performance Reviews and Improvement Plans
A practical guide for HR professionals on documenting performance conversations, annual reviews, PIPs, and disciplinary discussions in a way that is consistent, defensible, and useful to managers and employees alike.
How to Document Exposure and Response Prevention (ERP) Therapy for OCD
A practical guide for therapists providing ERP for OCD and related anxiety disorders on documenting exposure hierarchies, SUDS ratings, response prevention adherence, habituation tracking, and progress notes that meet both clinical and insurance standards.
How to Document Family Law Cases and Child Custody Evaluations
A practical guide for family law attorneys and custody evaluators on how to document cases effectively. Covers intake documentation, case chronology, custody evaluation reports, parenting plan documentation, financial disclosures, and court-ready standards.