Blog
How to Document Functional Behavior Assessments in Schools
A practical guide for school psychologists, behavior analysts, and special education teams on documenting FBAs from referral through BIP development, with IDEA compliance requirements.
How to Document Gastroenterology Patient Visits and Endoscopy Procedure Reports
A practical documentation guide for gastroenterologists, GI nurses, and endoscopy suite staff. Covers outpatient consultation notes, endoscopy and colonoscopy procedure reports, IBD management plans, hepatology visit notes, quality metrics, and common documentation pitfalls in high-volume GI practice.
How to Document Gastroenterology Patient Visits and GI Procedure Notes
A practical documentation guide for gastroenterologists, NPs, and PAs. Covers outpatient GI consultations, chronic condition follow-up visits, colonoscopy and endoscopy procedure reports, pathology integration, quality metrics, medication management, and CMS payer requirements for GI procedures.
How to Document Gastroenterology Patient Visits and Digestive Health Assessments
A practical guide for gastroenterologists, GI fellows, and nurse practitioners on documenting GI consultations, endoscopy and colonoscopy procedure notes, chronic disease management plans for IBD, GERD, and IBS, medication management, and quality metrics. Includes fictional examples of a new patient note, a colonoscopy procedure note, and an IBD follow-up.
How to Document Gender-Affirming Care and Therapy Sessions
A practical guide for therapists, counselors, and psychologists providing gender-affirming care. Covers WPATH Standards of Care documentation, referral letters for hormone therapy and surgery, gender dysphoria assessment under DSM-5-TR, informed consent vs. gatekeeping models, insurance prior authorization, and privacy protections specific to transgender and gender-diverse clients.
How to Document Genetic Counseling Sessions and Risk Assessments
A practical guide for certified genetic counselors on documenting genetic counseling sessions and risk assessments. Covers three-generation pedigree documentation, risk model records, variant interpretation, informed consent, pre-test and post-test counseling notes, results disclosure, cascade testing coordination, insurance pre-authorization, CPT billing, and documenting patient understanding of probabilistic information.
How to Document Geriatric Therapy and Older Adult Mental Health Sessions
A practical guide for therapists working with older adults on documenting cognitive screening scores, capacity assessments, Medicare requirements, caregiver coordination, and the clinical complexity that standard note formats do not fully address.
How to Document Gestalt Therapy Sessions
A practical guide for Gestalt therapists on translating experiential, process-oriented work into clinical records. Covers phenomenological observation, empty chair technique, body awareness, contact experiments, and how to satisfy insurance requirements without gutting the Gestalt framework.
How to Document Gifted Education Assessments and Twice-Exceptional Student Plans
A field guide for school psychologists and gifted education specialists on documenting gifted assessments, twice-exceptional (2e) student plans, IEP and 504 intersections, cognitive and achievement testing, acceleration decisions, differentiation plans, social-emotional needs, parent communication, and progress monitoring for advanced learners.
How to Document Gifted Education Evaluations and Twice-Exceptional Student Plans
A practical guide for school psychologists, gifted education specialists, and special education teams on documenting gifted identification evaluations, cognitive and achievement testing results, twice-exceptional (2e) student profiles, Advanced Learning Plans (ALPs), enrichment and acceleration recommendations, and progress monitoring for gifted services.
How to Document Gottman Method Couples Therapy Sessions
A practical guide to Gottman Method documentation for couples therapists. Learn how to capture Sound Relationship House assessments, Four Horsemen observations, Gottman Relationship Checkup results, and interventions like Dreams Within Conflict using SOAP and DAP formats that reflect relational patterns rather than individual pathology.
How to Document Grief and Bereavement Counseling Sessions
A practical guide for therapists on documenting grief counseling sessions. Learn how to handle non-linear progress, complicated grief screening, cultural considerations, and write clear SOAP and DAP notes for bereavement work.