I'm Dr. Maelisa McCaffrey and I started QA Prep to teach therapists how to create rock solid documentation so they can spend more time focusing on clients and less time worrying about paperwork!
Each Wednesday you'll find a new video answering therapist's questions about mental health documentation. We talk progress notes, treatment plans, therapy forms for private practice, and dealing with insurance.
I also post videos on any and everything related to technology for clinical documentation, HIPAA, time management and more.
Connect with our community via frequent livestream Q&A sessions, or post your own tips in the comments section of regular videos.
Пікірлер
extremely informative
Where's the link for intervention check list
@@amandahammons9272 it’s in the video description but you need to click on “read more” to see it. I’ll also link it here: www.qaprep.com/therapy-interventions-handout
are there any AI tools for writing final psychology reports for clients on discharge from the hospital or from private practice endings? Thanks for all your excellent help, by the way.
@@ernestberry5226 my Clinical Writer is on my list to review and helps with letters and reports! Check it out 😊
You’ve described exactly how I conduct intakes.😊
@@ernestberry5226 yay!!!
Thank you for the confirmation. That alone is so valuable . 🙏
Tbank you very helpful
Thoughts about gender affirming care letter requests?
@@LaviniaBailerina I would always keep things very fact based and stick with basics of care, since you never know the potential ramifications of a letter.
Yes, of course sticking to facts is always essential. The letter requirements however ask me as a clinician whether I believe the client would be able to deal with the repercussions of the surgery or do they have any other mental health issues that would make doing the gender confirming surgery Risk their mental health. And of course, this is asking for my opinion and speculation. I found my way around it, but I’m just curious about maybe this being a subject for another of your videos. I so appreciate the work you do to help us all!
What if we don’t use names or any specific details about the client, will it still be a HIPAA violation to use ChatGpt to paraphrase or write notes
@@kaylao.3326 it is impossible to write a note that is detailed enough to the client and maintain confidentiality. There are plenty of AI progress note generators that are HIPAA secure so I recommend using one of those instead.
My teachers couldn't explain this in 2 years Thank you for this
@@navikabansal9454 it’s surprisingly difficult to make things simple sometimes 😊
I’m so glad I found your channel. I’m a newly licensed LCMHCA and these are the areas I’m in most need of additional training. Gonna be checking out all your courses. Thank you !!!!❤
@@jasonbarney4278 and keep an eye out for the book coming out in October! 😉
This helps alot. Thank you!
Thank you Maelisa - always good as a reminder. I remember about 15 years ago going to a CAMFT conference in San Jose and listening to a sex therapist and his main thing was, "first session - how you build rapport with client!" I remember being surprised and pleased. And of course check in after the first session...make sense!! You are wonderful...so simple and concrete!
@@trishannelininger1206 so glad this was a helpful reminder! It’s sad (and very understandable) that insurance and legal requirements tend to lead us astray from the main goal.
So true. Unethical therapists never seek help.
@@maribelflores6470 yes, the ones who are worried about doing well are likely doing well already… and that’s part of what makes them good! 😊
I appreciate this video and I have implemented this simple and effective method of creating treatment plans for my part-time private practice work. Unfortunately, in my full-time work at a mega-corporation owned behavioral health center, they recently implemented a training on treatment plans wherein it was explicitly stated "Goals which focus on triggers and coping skills are overused and should be avoided."🙄
Doctor, I need to buy your documentation paperwork for my new practice. Can you help me buy resources for documentation? Thank you
Does insurance (specifically Medicaid) seem to require Goals and Objectives?
@@TabithaSelerowski Medicare wants a client goal as a quote, which can be the “long term goal” and then you would write SMART goals but no, I have not seen them require objectives on top of that.
you have no idea how helpful your sample statements for late Notes are😂
I really appreciate your presentation! You answered all of my questions, and I feel less anxious now. 🤗
Helpful review but I clicked on the link for the sample notes and it was never sent to me (checked spam and promotions folders)😕
@@AMitra61853 sorry about that! Email [email protected] and we’ll make sure you are set up 😊
Ditto on the default note. Beautifully written interventions, broken down so you could integrate with IFS, CBT, DBT, etc.
Are you talking about long term treatment goals or short term ones?
@@geevee4130 same thing. I’m saying that for most private practice settings you only need a couple basic goals. Medicare and Medicaid often does like to see a long term goal that is a direct quote from the client but as far as the SMART goals a clinician has to write, keep it to these 2-3. Total.
🎉 Connect with the client during intake. 2. Have the client complete the paperwork beforehand. 3. Ask the client what is the most important for her/him/them for their goals. Intake does not have to be completed immediately. It can be done during the next few sessions. 4. Use timely questions depending on the situation. Ask, "What is it like for you being here?". You can also ask What is most pressing for you at this time? Ask for feedback from the client. What they might change and what they need.
These seem pretty obvious.
Thank you for the help, I feel less anxious about my notes
@@bridgettcade5526 that’s so great to hear!
I need all the documents needed for private practice. Can I buy it from you?
@@aminatabongay7919 the upcoming book will have all the templates needed or you can check out the current paperwork packet here: www.qaprep.com/paperwork-packet
Thank you, Maelisa, for reviewing our product! Your insights have greatly helped us improve SessionAid. We're always here to answer any questions. If you have any inquiries about SessionAid or how AI works for therapist note-taking, please leave a comment! We hope SessionAid or another solution can help make documentation much less stressful! Best, Uzzi Co-founder @ SessionAid
Out of curiosity, will an insurance company recoup money if they don’t like your goals or if they are not SMART goals?
@@freerangethinker5151 not if they don’t “like” the goals, but if the goals aren’t related to the symptoms, diagnosis, and impairment. And if the notes don’t relate to the goals, there’s also potential.
Do you sell a intake or general paperwork packet?
I do! However, we'll be phasing it out once my book is released in October 2024 so you may just want to check out the book instead (which will have all the templates): www.qaprep.com/stress-free-documentation-book
Great video
wonderful
OMG- I love this, thanks for sharing.
Thanks for your series reviewing AI clinical note tools - we are currently looking at both an EHR and notes tools so this has been invaluable, especially your testing with Rodgers' Gloria session. Looking forward to your review of Heidi and the EHR reviews.
@@menzietta5371 thank you so much!
Thanks, this is great!
As a program director and a small group practice owner, this was very helpful!
I am a clinician at group practice for first time. I assumed I would have supervision/or group consultation with other clinicians. But they don’t make time for that. It is kinda disappointing because I was solo prior and finally decided to be with others for support. I still feel so alone at a place with 3 other full time therapists. All these of these things is how I feel. ❤
@@elzona1983 oh that’s unfortunate and I’m sorry to hear that! Keep looking. It’s so wonderful when you find your community!
hehehe...I need 3 for this project I'm working on, but this certainly gets me moving in the direction I to be going in, Thank you so much for your good insights.
This is great! I believe you said you would share a checklist and a link for your Privacy Policy but I do not see either, I may have misunderstood. Thank you! :)
Sorry it's confusing but that was within the course. This is the older version of a module within a course I sell. However, here is the link to a free privacy policy: docs.google.com/document/d/1yMQHSg4jPEupOpRCnlkpIjujl6SCxECam4iXJAVBKS0/edit?usp=sharing
Thanks!
Aw, thank you so much! It means a lot 😊
Excited for your book!
Thank you!
Looking forward to your book!
Hi I have a question For subjective and objective complaints body part mentioned are spine and right shoulder However for intervention performed for hot moist pack and EMS spine is mentioned and for therapeutic exercise and neuro muscular education just time is provided so will we consider that for right shoulder based on subjective and objective complaints???
Sorry, I’m not able to offer guidance on medical notes! I know mental health and psychiatry but can’t answer that one.
@@MaelisaMcCaffrey no problem thank you for the reply
Thank you for this overview!! Very helpful! I just did a demo with them and they have added the customization feature allowing the clinician to limit the length of the casenotes and they are going to add the ability to integrate with Simple Practice "soon."
Awesome! I had a feeling Simple Practice would add a feature like this soon, wonder how long til this occurs? 😊
Hi Maelisa, in the sample notes that I downloaded of "Gloria" from your session, you have something about "as is" notes and notes "with additional prompts." What do you mean by that? Can you converse with the AI to get it to improve the note?
Some of them allow you to provide additional prompts to improve the note. And some allow you to further personalize the template by providing additional prompts within the template provided.
Hi there! We've made much improvement to our notes since Maelisa gave us a review! You can definitely make updates to your note templates generated for you. One thing we are working on is adding the ability to improve the generated notes on the fly with your feedback. Would love to talk to you more about what works for you.
If you use the default progress note created by upheal, it includes interventions the clinician provided.
I’d never heard of collaborative documentation before and I’m grateful there’s such a thorough video on the topic, thanks!
So glad this helped!
I thank you sooooo much for this. I don't know why notes just always seem to be so extreme for me. This is quick and to the point. Thanks again.
Are there any you recommend people consider using over others?
Not really. Partly because they are all changing so rapidly and partly because everyone likes something different.
Thank you so much, this was very helpful! I've been in the midst of creating my forms for some weeks and this video confirms I'm on the right track, which makes me feel really good because I've stressed out over a lot of this (not just the forms, but getting the whole practice together). I need to check and possibly tweak a few things, but I believe I'm finally close to being done with all my paperwork. Thanks again Maelisa, several of your videos have been helpful to me in this process. 🙂
This is so great to hear!
Thank you for your videos! My wife is a new therapist and is looking for a therapy notes software or website that helps her with reducing the amount of time she takes to do notes. I’ve watched a few videos you’ve produced and really appreciate them! I have a few questions I’d love to run by you for your advice: 1. Could you share which “notes only” software/website product you like the best that also includes AI? 2. I’ve looked at Note Designer as another option to consider and wanted to also get your feedback on that product? 3. Do you have any video reviews on it?
I don't have any reviews on Note Designer. I hear mixed opinions - for some it is overwhelming while others find it helpful. I recommend going through it (or any other resource like it) and identifying the top 10-15 helpful phrases. Copy those down to use and then don't worry about looking at it again.
As far as a favorite AI progress note generator, I really don't have a favorite. They are all different and it's based on personal preference and budget.
I appreciate your videos so much as note writing has been such a challenge for me. I’m an Associate and my agency will not allow us to use bulletpoints citing that insurance companies reject any notes written in any shortcut form. You’re spot on about how laborious and excruciating it feels to me so I avoid the task. After seeing 6-7 clients a day I don’t have the mental capacity to write anything.
They’re wrong about the bullet points but when you work in an agency you have to go with their rules. Try creating starter sentences for yourself to use as a cheat sheet instead 😉
@@MaelisaMcCaffrey thank you
0:00 Intro 1:39 How Does it actually work? 4:39 Pricing 5:28 How well does it integrate with my EHR? 6:39 What are my favorite features? 9:05 Any cautions or concerns? 12:53 How well did it actually write a progress note? 17:00 Overall assessment 17:46 Outro
What about for peer support
Funny, not-funny: Grief, Stress, Burnout on TOP of chronic "note struggles!"
Yup, such a common therapist experience!