Blog
How to Document Solution-Focused Brief Therapy (SFBT) Sessions
A comprehensive guide for therapists on documenting Solution-Focused Brief Therapy sessions. Covers the miracle question, scaling questions, exception-finding, compliments, and task assignments in SOAP and DAP formats that satisfy insurance reviewers without distorting SFBT's strengths-based approach.
How to Document Somatic Experiencing and Body-Based Therapy Sessions
A comprehensive guide for somatic experiencing practitioners and body-based therapists on documenting sessions where the primary clinical data is physiological. Covers nervous system state tracking, titration and pendulation, activation and discharge cycles, and how to adapt SOAP and DAP formats for somatic work.
How to Document Speech-Language Pathology IEP Goals and School-Based Services
A practical guide for school-based speech-language pathologists on documenting IEP goals, progress monitoring, and service delivery. Covers IDEA compliance, writing measurable goals with benchmarks, progress reporting formats, Medicaid billing documentation, and common documentation errors that lead to audit findings across large SLP caseloads.
How to Document Speech-Language Pathology Sessions and Progress Reports
A practical guide for SLPs on documenting evaluations, treatment sessions, and progress reports. Covers SOAP format adapted for speech therapy, functional outcome measures, medical necessity language, pediatric vs adult documentation, school-based vs clinical settings, and common SLP documentation mistakes.
How to Document Speech-Language Pathology Sessions and Therapy Progress
A practical guide for SLPs on documenting therapy sessions across settings. Covers SOAP notes for speech therapy, articulation data collection, language goal tracking, fluency treatment notes, dysphagia session documentation, IEP-related documentation, Medicaid requirements for SLP services, and common documentation mistakes that create audit exposure.
How to Document Student Accommodations
Learn how to properly document student accommodations for IEPs and 504 plans. Covers selection, implementation tracking, and compliance requirements.
How to Document Student Threat Assessments and Behavioral Risk Evaluations in Schools
A practical guide for school psychologists, counselors, administrators, and threat assessment team members on documenting student threat assessments and behavioral risk evaluations. Covers CSTAG documentation requirements, transient vs substantive threats, factual vs speculative writing, FERPA considerations, safety plans, law enforcement coordination, and common documentation mistakes.
How to Document Substance Abuse and Addiction Counseling Sessions
A practical guide for addiction counselors, social workers, and therapists on writing progress notes that hold up to audits, support continuity of care, and capture the clinical complexity of SUD treatment.
How to Document Substance Use Disorder Treatment Sessions
A practical guide for therapists and counselors on documenting SUD treatment, from initial screening and treatment planning to motivational interviewing notes, relapse prevention, court-mandated treatment, and 42 CFR Part 2 privacy requirements.
How to Document Supervision Notes for Associate Therapists
A practical supervision documentation guide for clinical supervisors and associate therapists. Learn what to capture in supervision notes, what to avoid, and how to keep records clinically useful and legally defensible.
How to Document Surgical Procedures and Operative Reports
A comprehensive guide for surgeons, surgical residents, and surgical PAs on writing complete, audit-ready operative reports. Covers required elements, timing rules, dictation strategy, and common deficiencies.
How to Document Therapy for Clients with Intellectual and Developmental Disabilities
A practical guide for therapists and behavioral health providers on documenting therapy sessions with clients who have intellectual and developmental disabilities (I/DD), including capacity and consent, behavioral observations, guardian involvement, and multi-provider coordination.