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Course Detail

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Course # 71072 • 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.

Education Category: Management

Release Date: 07/01/2020

Expiration Date: 06/30/2023


This course is designed for all licensed behavioral healthcare professionals, including social workers, counselors, and therapists.


NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. NetCE maintains responsibility for this course. This course, Beyond Therapy: The Basics of Clinical Documentations, Approval #190304-556R, provided by NetCE, is approved for continuing education by the New Jersey Social Work Continuing Education Approval Collaborative, which is administered by NASW-NJ. CE Approval Collaborative Approval Period: September 1, 2020 through August 31, 2022. New Jersey social workers will receive 4 General CE credits for participating in this course. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors. #MHC-0021.This course is considered self-study by the New York State Board of Mental Health Counseling. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy.

Designations of Credit

NetCE designates this continuing education activity for 1.5 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 4 Non-Clinical continuing education clock hours. NetCE is authorized by IACET to offer 0.4 CEU(s) for this program. NetCE designates this continuing education activity for 4 credit(s).

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011;

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 Planners

Alice Yick Flanagan, PhD, MSW

James Trent, PhD

Division Planners Disclosure

The division planners have 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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