Blog
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 Bankruptcy and Debt Relief Cases
A practical guide for solo and small-firm bankruptcy attorneys on documenting Chapter 7 and Chapter 13 cases. Covers means test worksheets, 341 meeting preparation, asset schedules, debtor counseling certificates, adversary proceedings, plan modifications, discharge records, and client communication logs across a high-volume consumer practice.
How to Document Bankruptcy Cases and Debt Relief Client Communications
A practical guide for bankruptcy attorneys, paralegals, and legal aid staff on documenting Chapter 7, Chapter 11, and Chapter 13 cases. Covers initial intake, asset disclosure, debt schedules, means test records, petition preparation, creditor communications, 341 meeting notes, plan modifications, adversary proceedings, and discharge documentation.
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 Behavioral Parent Training and Caregiver Coaching Sessions
A comprehensive guide for child and family therapists on documenting parent training interventions including PCIT, PMT, Triple P, and caregiver coaching. Covers note structure, skill acquisition tracking, and common documentation mistakes.
How to Document Bipolar Disorder Treatment and Mood Episode Tracking
A practical guide for therapists and prescribers on documenting bipolar disorder treatment sessions. Covers mood episode tracking, mixed states, rapid cycling, safety assessment during mania, psychoeducation, and collaborative care documentation across bipolar I, II, and cyclothymia.
How to Document Body Dysmorphic Disorder (BDD) Assessment and Treatment
A comprehensive guide for therapists treating BDD on documenting BDD-YBOCS assessments, appearance-related beliefs, mirror exposure and ritual prevention, cognitive restructuring, body checking and avoidance behaviors, dermatological procedure-seeking, and progress measurement with validated BDD instruments.
How to Document Borderline Personality Disorder Treatment: Progress Notes for DBT, Schema Therapy, and MBT
A clinical documentation guide for therapists treating BPD. Covers diagnostic assessment and differential diagnosis, DBT diary card documentation, behavioral chain analysis, crisis and safety planning for chronic suicidality, therapeutic alliance rupture-repair cycles, schema therapy mode tracking, MBT mentalizing stance documentation, medication coordination, functional impairment, and common documentation mistakes.
How to Document Brainspotting Therapy Sessions
A practical guide for Brainspotting-trained therapists on documenting BSP sessions. Covers the six-phase model, activation scale tracking, gaze point documentation, body awareness notes, Focused vs Natural Brainspotting differences, resource model documentation, neurobiological processing notes, billing, and common documentation mistakes.
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 Cardiology Patient Visits and Heart Failure Management Plans
A practical documentation guide for cardiologists, NPs, and PAs. Covers initial consultations, follow-up visit structure, heart failure staging and management documentation, EKG and echo interpretation notes, cardiac procedure records, device management, and quality reporting requirements.
How to Document CBT for Insomnia (CBT-I) Sessions
A practical guide for therapists delivering Cognitive Behavioral Therapy for Insomnia. Covers sleep diary data integration, stimulus control and sleep restriction parameter tracking, sleep efficiency calculation, the multi-session protocol structure, hypnotic taper coordination, validated outcome measures like the ISI and PSQI, and documentation for comorbid presentations.