Essential Clinical Forms Package
$287.00
Essential Documentation from Intake to Discharge.
Satisfies Medicare Regulations and Medical Necessity Guidelines
Developed to meet Medicare standards, the Documentation Wizard Clinical Forms initiate the Golden Thread with the Intake Summary and maintain it right through to the Discharge Summary.
The Documentation Clinical Forms provide a high level of structure not seen in other clinical forms.
DW Forms are not generic templates with limiting dropdown menus, predefined answers, or constrained by limited space. These types of templates are designed primarily for reimbursement purposes.
Because all the content needed has been distilled into discrete categories and sections, the formatting is deceivingly simple. For Example, there’s not one big box for “Clinical content” or another for “Assessment comments,” leaving you to wonder what clinical content to include and what of the 6 assessments in a session note to address! The Documentation Wizard Clinical Forms provide prompts for all clinical content and assessments! This helps you create a cohesive narrative without telling the details of the story.
That took 1000s of hours of work. So, they are simple to use. But not simplistic. And they’ve been reviewed by three attorneys, countless clinicians, and a bioethicist with 2 thumbs up.
The Documentation Wizard Clinical Forms:
- include the mandated insurance content
- provide all the prompts necessary to justify medical necessity
- enhance your clinical thinking, protect client confidentiality and protect your income.
- include selective dropdown menus and checkboxes to assist with quick completion.
But that’s not all! The DW Clinical Forms:
- include all the clinical content that helps you assess a client’s progress, and
- provide space for short narratives where needed or required so your clinical voice and practice needs can and should be heard.
In other words, designed around a simple (but not simplistic) formula, the Documentation Wizard Clinical Forms take the guess work out of what and how much to write. They help reduce Documentation Anxiety!
The DW Clinical Forms can be customized to meet your clinical needs and stored in a paper file or on your computer. You may be able to upload the forms into your digital program or use them to augment your online system. Please check with your practice management system for confirmation.
1. Intake Summary or Bio-Psycho-Social Assessment
The Golden Thread starts here. The Intake Summary acts as the foundation for your treatment plan. A good one contains the information to help determine the prognosis of your client from a strengths based perspective. The Intake Summary includes:
- contact and emergency contact information
- religious/spiritual affiliation and its meaning in client’s life
- education, work, and medical histories
- a thorough mental health history
- possible legal involvement
- a culturally competent and inclusive trauma assessment
- birth/foster/adoptive family mental health history
- substance use history/inventory
- risk factors and barriers to treatment
- reason client seeks services
- client strengths
- … and many other requirements.
Encourage your client to complete the Intake Summary and bring or send it prior to starting treatment. See how smooth the first interview can be and how it helps you determine a diagnosis.
2. & 3. Treatment Plan and the Treatment Plan Review
The Golden Thread continues by weaving a picture of the client’s problematic behaviors or “functional challenges” with hoped for goals, an assessment of prognosis and eventual progress. It delivers the criteria for justifying medical necessity and includes:
- diagnosis
- presenting problem in behavioral terms (the required language of documentation)
- goals
- barriers to treatment
- objectives
- interventions
- clinical assessments
- risk assessment
- progress
- resources recommended
- duration and frequency of treatment
- the reasons for medical necessity
- … and many other requirements.
Once you write a Documentation Wizard Treatment Plan, you’ll feel confident that you can write a plan that is customized to your client, is clinically useful, and can pass an audit.
4. Progress Note
Standard SOAP and DAP note templates can be vague, including ambiguous prompts like, “Clinical Content” and “Clinical Assessment.” In the quest to be thorough, clinicians often write long stories with unnecessary content and redundant assessments. Or they write too little, afraid of revealing confidential information. The result is wasted time, potential lost income from an audit or board complaint, and anxiety about the process.
The Documentation Wizard Progress Note provides a structured template that clarifies what and how much to write by breaking down clinical content and 6 different types of assessments into specific sections and naming them.
Because all the content needed has been distilled into discrete categories and sections, the formatting is deceivingly simple. For example, there’s not one big box for “Clinical Content” or another for “Assessment Comments,” leaving you to wonder what clinical content to include and what of the 6 assessments in a progress note to address! The Documentation Wizard Clinical Forms provide prompts for all clinical content and assessments! This helps you create a cohesive narrative without telling the details of the story.
The Documentation Wizard Session Note leaves no stone unturned. It includes:
- start and stop times
- the diagnosis
- CPT Code dropdown menus that include family, crisis and add-on codes
- severity dropdown menus
- risk factors & barriers to treatment
- telehealth protocol confirmations
- specific sections to document the 6 areas of “clinical assessment”
- 47 checkboxes for a mental status exam and a way to customize them for your practice.
- 30 checkboxes of possible interventions and a way to customize them for your practice.
- space to write a short narrative to explain your interventions.
- checkboxes for a thorough risk assessment
- a reminder to justify using 90837 (if necessary)
- a reminder to justify a second session of the week (if necessary)
- client’s response to treatment
- plan, progress, prognosis
- verification of medical necessity
- a way to explain veering from the treatment plan without rewriting it before it’s due.
- a way to document no-shows and cancellations
- … and many other requirements
The most frequently written document, session notes should be a snap to write. The Documentation Wizard Session Note takes the guess work out of what and how much to write.
5. Case/Collateral Consult Note
The Golden Thread is enhanced by writing case and collateral consult notes. They are critical to quality care and demonstrating best practice. Whether you are at an IEP meeting for a child, working with a probation officer, or speaking with a prescriber or former therapist, consult notes can help justify medical necessity and help protect you in case of a board complaint. The Golden Thread continues to weave through as the consult note shows that treatment is discussed and evaluated with others. This consultation notes includes:
- diagnosis
- date of consult
- start and stop time of consult
- reason for consult additional checkboxes
- who’s present and relationship to client
- actions to be taken as a result of consult
- … and much more.
Protect yourself and your client by documenting your phone, video, and in person consultations.
6. Discharge Summary
The Golden Thread ends with the Discharge Summary. It’s an inclusive and specific review of treatment that reflects the treatment plan, verifies treatment has ended and why. Neglecting to write a discharge summary can leave you open to legal issues and board complaints. The Documentation Wizard Discharge Summary includes:
- an inclusive and specific review of treatment that reflects the treatment plan
- reason for discharge
- condition at discharge
- follow-up recommendations
- confirmation that the client was notified
- … and much more.
Write a Discharge Summary that protects you from legal problems and supports your client in knowing what’s next for them.
7. Summary of Treatment
A Summary of Treatment can often be used in place of a treatment plan for situations other than an audit. For example, it can often be used in a request for a disability review, a Workman’s Comp claim, and is often used to satisfy a Risk Assessment Audit. A Summary of Treatment can be used when treatment information is needed and there is no risk of a recoupment. Take the struggle out of compliance with this Summary of Treatment template. It cues you to include all the required information in a logical step-by-step process.
In Addition to the Downloadable Forms, You Will Also Receive …
- THREE SETS OF EXAMPLE FORMS:
- Example Forms for Case #1 – a real life example for a client with Major Depressive Disorder during the Pandemic.
- Example Forms for Case #2 – a real life example for a client with Binge Eating Disorder and a therapeutic breech.
- Example Forms for Case #3 – a real life example for a client with PTSD and legal involvement.
- Extensive list of Barriers to Treatment
- Tips for Completing Outpatient Reviews
- Video with Beth demonstrating how to complete a Progress Note using a Fillable PDF (it’s like a mini documentation training!)
- Video with Beth demonstrating how to complete a Progress Note using a Word Doc (it’s like a mini documentation training!)
- Since starting anything new can be challenging, 3 weekly emails with tips on how to streamline the use your new forms.
Are Clinical Forms Compatible with Treatment Planning Books?
Clinical Forms may be used with or without a treatment planning book. The decision depends on your comfort using your own clinical voice as you represent the modalities you use in treatment. A treatment planning book is NOT included with this purchase.
Formatting of Clinical Forms
Clinical Forms are available as both Word Docs and Fillable PDFs. Both versions can be customized to meet your clinical needs and used in conjunction with many online systems. You get both with your purchase so you can try each to decide what works best for your practice. For best results, we recommend using the most recent version of Microsoft Word in Microsoft 365 and Adobe Reader.
Learn more about how to customize your forms and get your technical questions answered here: Technical FAQs
Become a Documentation Wizard
Essential Clinical Forms Package
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$287
