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Course # 61071 • Beyond Therapy: The Basics of Clinical Documentation


Throughout the course of their training, behavioral health providers learn to be clinicians, to engage clients, understand the theoretical basis for treatment, develop an understanding of mental illnesses, and become advocates for their clients' well-being. Unfortunately, most clinicians are poorly trained in the administrative and regulatory aspects that impact their work, a significant aspect of which is documentation. Documentation, the primary focus of clinical chart audits, is scrutinized by regulatory bodies. Among other things, chart audits assess for medical necessity to determine whether or not the treatment is necessary and/or effective. Documentation that does not support medically necessary treatment potentially results in a recoupment of disbursements and, in extreme cases, a loss of clinical licensure. Whether in an agency or private practice setting, all practicing behavioral health providers are required to meet regulatory standards of practice, and under healthcare reform, these standards are increasingly stringent. To meet the demands of these standards, clinicians must have a working knowledge of the process and an understating of the standards and requirements to which they are expected to adhere. Emphasis will be placed on learning medical necessity terminology and developing functional skills in clinical documentation.

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Education Category: Management

Release Date: 07/01/2017

Expiration Date: 06/30/2020


This introductory course is designed for psychologists in all practice settings.


Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.

Designations of Credit

NetCE designates this continuing education activity for 4 credit(s).

Course Objective

The purpose of this course is to provide clinicians with a broader understanding of documentation and its relationship to the standards of practice governed by regulatory bodies in order to fully support client care.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Outline the regulatory requirements affecting clinical documentation.
  2. Describe the necessary components of mental health assessments.
  3. Evaluate the role of documentation in treatment planning.
  4. Discuss the proper creation of progress notes.
  5. Identify the necessary parts of discharge summaries.


Lisa Kathryn Jackson, MA, LPCC, NCC, received her Master’s of Arts degree with a dual emphasis in Community and School Counseling from the University of New Mexico, Albuquerque, in 2006. After graduating, Ms. Jackson practiced as an outpatient psychotherapist providing treatment to children, adolescents, couples, families, and adults. In 2007, she relocated to Durango, Colorado, where, as a triage clinician, she provided mental health assessments and diagnoses for a multi-access behavioral health facility (inpatient, outpatient, and substance abuse services). Ms. Jackson returned to Albuquerque, New Mexico, in 2008, where she started and maintained a private practice, earned certification in Wholistic Kinesiology, and was the Clinical Supervisor for a crisis intervention program in the local school district. Ms. Jackson went on to become the interim Clinical Director for a community mental health agency, managing clinical and case management staff, developing staff trainings, and overseeing the administration of clinical processes required by the state of New Mexico.

In her eight years of clinical work, Ms. Jackson has written more than 2,500 mental health assessments and reviewed hundreds of clinical records for medical necessity. She continues her clinical work as a Behavioral Health Care Manager in a managed care setting reviewing clinical documentation from mental health providers throughout the state of New Mexico. Most recently, Ms. Jackson was accepted to a Master’s of Arts degree program where she will earn a Master’s of Public Health degree.

Faculty Disclosure

Contributing faculty, Lisa Kathryn Jackson, MA, LPCC, NCC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

James Trent, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Technical Requirements

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