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 Acupuncture Sessions and Traditional Chinese Medicine Treatments
A practical guide for licensed acupuncturists on adapting SOAP format for TCM, documenting point prescriptions and meridian assessments, recording tongue and pulse diagnosis, writing insurance-compliant treatment rationale, and tracking progress across a treatment series.
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 Adoption Home Studies and Post-Placement Supervision Reports
A practical guide for social workers and adoption professionals on documenting home studies and post-placement supervision reports that meet state and agency requirements. Covers psychosocial assessment components, safety documentation, how to write without editorializing, and the common mistakes that delay or derail adoption proceedings.
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 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 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.