Blog
How to Document Acceptance and Commitment Therapy (ACT) Sessions
A practical guide for ACT therapists on how to document the six core processes in progress notes. Covers cognitive defusion, acceptance, present moment awareness, self-as-context, values clarification, and committed action without reducing ACT's experiential richness to checkbox language. Includes fictional examples and a documentation checklist.
How to Document ADHD Evaluations and Treatment in Clinical Practice
A practical guide for clinicians on documenting ADHD evaluations, multi-informant assessments, rating scale interpretation, treatment planning, medication monitoring, and school coordination. Covers the full documentation lifecycle from referral through ongoing treatment, common documentation mistakes, and audit-readiness.
How to Document Applied Behavior Analysis (ABA) Therapy Sessions
A practical guide for BCBAs and RBTs on documenting ABA therapy sessions. Covers session note structure, data collection, behavior reduction, skill acquisition tracking, insurance requirements, and common documentation mistakes.
How to Document Art Therapy Sessions
A practical guide for art therapists and expressive therapists on documenting sessions that involve creative media. Covers what makes art therapy documentation unique, adapted note formats, ethical considerations for artwork storage and photography, and common documentation mistakes.
How to Document Audiology Evaluations and Hearing Aid Fitting Reports
A practical guide for audiologists, hearing instrument specialists, and audiology assistants covering documentation of audiometric evaluations, hearing aid fittings, cochlear implant evaluations, tinnitus assessments, vestibular referrals, and follow-up visits.
How to Document Autism Spectrum Evaluations and Support Plans
A practical guide for psychologists, school psychologists, and multidisciplinary teams on documenting autism spectrum evaluations. Covers ADOS-2 and ADI-R documentation, evaluation report structure, support plan writing across clinical and educational settings, cross-provider coordination, and common documentation mistakes that delay services.
How to Document Behavioral Health Screenings in Primary Care: PHQ-9, GAD-7, and Integrated Care Workflows
A practical guide for primary care providers, nurse practitioners, PAs, and behavioral health consultants on documenting standardized behavioral health screenings, positive screen follow-up, integrated care workflows, warm handoffs, and billing codes including 96127 and G-codes. Covers common audit errors and fictional patient examples.
How to Document Cardiac Rehabilitation Sessions and Patient Progress Reports
A practical guide for cardiac rehab nurses, exercise physiologists, and program coordinators on documenting intake, monitored exercise sessions, outcomes tracking, and Medicare compliance across Phase I, II, and III.
How to Document Child and Adolescent Therapy Sessions
A comprehensive guide for therapists who work with minors on the unique documentation requirements of child and adolescent therapy. Covers play therapy observations, parental involvement, school coordination, mandatory reporting, and SOAP format adapted for child work.
How to Document Chiropractic Patient Visits and Treatment Plans
A comprehensive guide for chiropractors on documenting initial evaluations, daily SOAP notes, re-examination reports, and insurance-compliant treatment plans. Covers audit risk, common documentation mistakes, and how structured templates protect your practice.
How to Document Chronic Pain Management and Opioid Prescribing
A practical guide for physicians, nurse practitioners, and PAs on documenting chronic pain visits, opioid prescribing decisions, PDMP checks, urine drug screens, risk stratification, treatment agreements, and tapering plans. Covers DEA and state regulatory requirements and how to write notes that demonstrate clinical reasoning for controlled substance prescribing.
How to Document Client Interventions
Guide to documenting social work interventions effectively. Covers intervention types, linking to treatment goals, measuring outcomes, and avoiding common errors.