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 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 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.
How to Document Group Therapy Sessions
A practical guide to group therapy documentation for licensed clinicians. Learn what to include in group notes, how to handle confidentiality, and how to document therapeutic factors and critical incidents.
How to Document Home-Based Therapy and In-Home Counseling Sessions
A practical guide for therapists and social workers who provide in-home therapeutic services. Covers what makes home-based documentation different from office-based work, required elements for home visit notes, how to adapt SOAP and DAP formats for community settings, Medicaid billing distinctions, and strategies for documenting in the field.
How to Document Home Health Nursing Visits and Patient Assessments
A practical guide for home health nurses on documenting patient visits that satisfy CMS OASIS requirements, support continued authorization, and capture the clinical picture accurately when working without hospital infrastructure.
How to Document Home Health Nursing Visits and Plan of Care Updates
A practical guide for home health nurses on documenting skilled nursing visits, OASIS-E assessments, homebound status, medication reconciliation, wound care, and the 60-day plan of care recertification cycle for Medicare compliance.
How to Document Homelessness Services and Supportive Housing Case Management
A practical guide for social workers and case managers on documenting homeless services, HUD HMIS requirements, Coordinated Entry assessments, supportive housing case notes, and maintaining documentation quality with high caseloads in resource-limited settings.
How to Document Hospice and Palliative Care Visits
A comprehensive guide for hospice and palliative care clinicians on documenting home visits, symptom management, goals-of-care conversations, pain assessments, functional decline, and interdisciplinary team meetings. Covers Medicare compliance, recertification documentation, and how to write notes that accurately reflect patient status while supporting continued eligibility.