Blog
How to Document Dialectical Behavior Therapy (DBT) Sessions
A practical guide for DBT therapists on how to document individual sessions, skills group, phone coaching contacts, and consultation team meetings. Covers diary card documentation, chain analysis, behavioral targets hierarchy, skills module tracking, and how to write progress notes that capture DBT-specific interventions without losing the nuance of the modality.
Digital vs Paper Documentation: Pros and Cons
An honest comparison of digital and paper documentation for licensed professionals. Covers security, efficiency, compliance, cost, and disaster recovery.
Documentation Dos and Don'ts for Licensed Professionals
Universal documentation rules for therapists, physicians, lawyers, social workers, and educators. What to include, what to avoid, and how to stay protected.
Documentation Guide for Pre-Licensed Therapists and Clinical Interns
A practical documentation guide for associate therapists, interns, and clinical residents. Covers required elements for supervised hours, common mistakes that jeopardize licensure, and how to build sustainable note-writing habits from day one.
Documentation Tips for Paralegals
Practical documentation tips for paralegals covering note-taking, file management, deadline tracking, and communication logging. Improve accuracy and efficiency.
How to Document Functional Behavior Assessments
A comprehensive guide for school psychologists, behavior analysts, and special educators on documenting FBAs. Covers IDEA legal requirements, ABC data recording, hypothesis statements, replacement behavior selection, and documentation errors that lead to due process complaints.
GIRP Notes for Therapists: A Complete Writing Guide with Examples
Learn how to write GIRP notes for therapy sessions. Step-by-step guide covering each section (Goal, Intervention, Response, Plan) with examples, when to use GIRP vs SOAP or BIRP, and adaptations for CBT, DBT, and psychodynamic approaches.
Group Therapy Notes: Documentation and Billing Checklist for Audit-Ready Progress Notes
A practical checklist for writing defensible group therapy notes that support clinical continuity and billing review. Learn what to document for attendance, interventions, participation, medical necessity, and individualized response without bloated charting.
HIPAA BAA Checklist for AI Documentation Tools
A practical checklist to evaluate Business Associate Agreements (BAAs) before using any AI documentation tool in clinical workflows.
HIPAA Documentation Requirements Explained
Plain-language guide to HIPAA documentation rules for clinical records. Covers the minimum necessary standard, release of information, electronic records, and more.
How Life and Executive Coaches Use Structured Documentation to Scale Client Outcomes
A practical guide for life coaches, executive coaches, and business coaches on building documentation systems that improve client retention, accountability, and practice growth. Covers what to document per session, proven frameworks, and how to manage records across a full client roster.
How Social Workers Can Evaluate AI Documentation Tools: A Privacy and Compliance Checklist
NASW has published no AI-specific documentation guidance since 2017. This guide fills that vacuum. Learn what social workers should look for in AI documentation tools: data handling, BAA availability, court subpoena exposure, 42 CFR Part 2, Medicaid audit risk, and a printable evaluation checklist.