Blog
How to Document a Mental Status Exam
Learn how to conduct and document a mental status exam (MSE) for therapy sessions. Covers every domain with clinical examples and common documentation mistakes.
How to Document Mindfulness-Based Cognitive Therapy (MBCT) Sessions
A practical guide for therapists on documenting MBCT sessions. Covers the unique challenges of group format documentation, home practice assignment tracking, mindfulness inquiry records, relapse prevention planning, and outcome measurement across an 8-week protocol.
How to Document Motivational Interviewing Sessions
A practical guide for therapists, social workers, and addiction counselors on documenting Motivational Interviewing sessions. Covers the MI spirit, change talk vs sustain talk, OARS techniques, stages of change, readiness rulers, and how to write progress notes that reflect MI-consistent practice. Includes fictional examples showing good vs poor documentation.
How to Document Music Therapy Sessions
A practical guide for music therapists on documenting sessions that involve musical interventions, improvisation, songwriting, instrument selection, and receptive techniques. Covers what makes music therapy documentation unique, adapted SOAP and DAP formats, how to describe musical responses and therapeutic outcomes, ethical considerations around recording, and common documentation mistakes.
How to Document Narrative Therapy Sessions
A practical guide for narrative therapists on documenting externalizing conversations, re-authoring narratives, outsider witness practices, and therapeutic letters in progress notes that meet insurance requirements.
How to Document Neuropsychological Evaluations and Testing Reports
A practical guide for psychologists and neuropsychologists on structuring evaluation reports, reporting normative scores, writing integrated summaries, and tailoring documentation for school, forensic, disability, and treatment contexts.
How to Document No-Shows, Late Cancellations, and Missed Appointments in Clinical Practice
A practical guide for therapists and clinicians on what to document when clients miss appointments, including billing implications, safety considerations, and how to handle recurring patterns.
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 Peer Consultation and Case Conference Sessions
A practical guide for therapists and clinical professionals on documenting peer consultation sessions, case conferences, and group supervision. Covers why documentation matters, what to include and what to leave out, note formats, confidentiality considerations, and common mistakes.
How to Document Play Therapy Sessions
A practical guide for child therapists on documenting play therapy sessions where interventions are non-verbal, symbolic, and process-oriented. Covers directive vs. non-directive approaches, developmental themes, parent consultation, and common documentation mistakes.
How to Document Prolonged Exposure (PE) Therapy for PTSD
A practical guide for trauma therapists on documenting Prolonged Exposure therapy. Learn what to capture across each PE component, how to track SUD ratings over time, what VA auditors and insurance reviewers need to see, and how PE documentation differs from EMDR and CPT.