Two types of good documentation practices examples will be discussed. Documents should always be kept up-to-date (i.e., reflect the latest version and contain the most recent data and information). SafetyCulture (formerly iAuditor) is a data entry software thats been included in Capterras 2021 Shortlist, GetApps 2021 Category Leaders, and Software Advices 2021 Frontrunners. Each review, check, or validation of data should be signed and dated by the reviewer. Not Followed: The contact number available to the employee is not the current contact number used by the customer. Hold an intensive training session that emphasizes the importance of good documentation practices and the real-life consequences of not following them (use example scenarios provided earlier). is a data entry software thats been included in, is free to download as a web-based software and as a mobile app. But the format will depend on your specialty and orientation (and whether or not you bill to insurance). Simply give them Inspection access to the template and they can digitally sign from wherever they are. Here are some of. Within SimplePractice, there are two types of paperless intake documents you can share with a client via the Client Portal to receive an electronic response. SimplePractice: Free Resources for your Private Practice In this post, we compare two such solutions TherapyNotes vs SimplePractice with insights from Nicole Lecherza-Drew, Psy.D., a licensed psychologist and owner of Vici Psychological Care. It should specify the exact error, why it had to be corrected, and why the correction made is suitable. Good documentation practices is a set of best practices for documentation and recordkeeping. Practice Administrators can upload practice-wide documents such as blank forms, service agreements, and handouts to share with other practice users. In this guide, we'll cover: Consent documents Editing an existing consent document Adding a new consent document Setting consent documents as default Intake forms Creating new intake forms Yes, there are some basic forms youll want at the ready prior to meeting clients. As soon as the employee texts that number to inform the customer that their desired item is in stock, the customer immediately replies and places an order. Good Documentation Practices Examples | SafetyCulture Not all states require you have written consent but it is required that you document getting informed consent from your clients. What do I have to talk about in my first meeting with them? Is it okay to email them the forms? Build reliable workflows for a streamlined approach and automatically save necessary data through cloud-based recordkeeping. This form is required by federal law if you are a HIPAA-covered entity; however, it is also becoming a standard of practice, especially if you use an electronic practice management system. An employee is performing a critical task and needs to refer to the SOP for that task. Access to data should be limited to authorized persons. for following good documentation practices easily: Take and annotate photos, log temperature readings, input numbers, type in text answers, and digitally sign documents. An organization that has a continuous improvement culture is composed of employees with questioning We use cookies to provide necessary website functionality and improve your experience. This way you spend your time focusing on the clinical purpose of the plan and not how to format it for every client. They are unable to answer the regulatory authoritys follow-up questions and are in danger of being deemed as non-compliant by the regulatory authority. Even while your internet connection is unstable, you can still use the SafetyCulture app to document key information for your business. Is it possible to do that? Maelisa Hall, PsyD is a clinical psychologist who teaches therapists how to create rock-solid documentation so they can spend more time with their clients and less time worrying about paperwork. These characteristics are the principles of good documentation practices. Leave a comment and share with us. Lets check them out a little more: This form is crucial! Either way, you want to review this with clients before it comes up as an issue. She has a free Private Practice Paperwork Crash Course available here. Customize any template to suit your needs and preferences or start using it immediately after downloading. Uploading documents - SimplePractice Support Eliminate manual tasks and streamline your operations. The employee doesnt know this and keeps calling the old contact number. Type of information: Evidence of compliance. Troubleshooting Online booking Documents and forms HOW DO I LOG IN? Followed: Since the business immediately knows who recorded the compliance data, they are able to ask that person for more information and even have them answer the follow-up questions of the regulatory authority directly. Or, click theHistory icon to view changes that have been made to the document over time. Dont worry- everything doesnt have to be perfect. Keep these notes short and sweet but dont skimp on the important stuff like missed sessions, follow up after a high-risk situation, and consultation with colleagues regarding ethical dilemmas. Document error correction by describing the error, noting the correction, and specifying why the error had to be corrected. [VIDEO]. As a result, the employee performs the task incorrectly and the output of the task is defective. Relationship with the company: Employee, Contractor, Supplier, or Other (Youll be asked to specify if Other is selected), Date of exit (If the person is no longer working with the company), ISO 45001:2018 Occupational Health & Safety Management, Getting started with SafetyCulture Platform, Signature Register/Signature Log Template, Why You Should Care About Good Documentation Practices, ALCOA Principles of Good Documentation Practices, Good Documentation Practices Dos and Donts, Good Documentation Practices Implementation, Follow Good Documentation Practices with SafetyCulture, SafetyCulture for Good Documentation Practices, What is Standard Operating Procedure (SOP)? To send a Library document to a client, go to the Portal tabof the client's chart, click theShare Documentsbutton, and search for the document to add to your document request. Documentation SimplePractice Support Working with your clients Documentation and Paperless Intakes Documentation Paperless Intakes Documentation Documentation Streamline your entire documentation workflow, and spend more time with your clients. Any user in the practice can view and download documents shared by Practice Administrators in the Document Library. For more information,read How To: Upload Practice Documents. What is it: Legible means that data is easily readable and understandable. Affix digital signatures for error corrections, data reviews, and document approval. Billing Documents - SimplePractice Support If needed, permission to edit the document must also be specified according to the level of access. TherapyNotes vs SimplePractice: A practitioner weighs in Any issues with the validity or truthfulness of data must be investigated further. Get the latest in your inbox. Does someone have some templates for me?. With SimplePractice's client portal, clients can fill out intakes, request appointments, send messages, pay bills, & more, from a secure client portal Start your free trial today Each principle is discussed in detail below. SafetyCulture is free to download as a web-based software and as a mobile app. The key is to make sure you collect enough information to provide appropriate treatment for each individual and refer to other specialists when necessary. 1 year ago. No need to get overwhelmed! His experience in logistics, banking and financial services, and retail helps enrich the quality of information in his articles. Click the Edit iconto edit document properties (including whether or not the document is eligible for sharing on TherapyPortal), archive the document, or delete the document. Assign enforcement responsibility to a Quality Assurance (QA) team lead or create a QA team specifically for enforcing good documentation practices. However, if you provide psychoanalytic work with young adults you likely dont need so much detail. Follow the ALCOA principles that make up data integrity and are the cornerstone of good documentation practices. As much as possible, data should be recorded in an electronic document or through the use of a computerized system. What is it: Attributable means that you know where the data came from (who recorded it). Avoid handwritten documentation. Fostering Aha Moments Through Slowing Down, If youre at the point where you think you need a biller for your private practice, you probably do. Each correction must be signed and dated by the one who performed the correction (which should also be the person who recorded the data containing the error). Information should flow logically and be organized in such a way that it is easy to make sense of the data or mentally process it. It's important to weigh the pros and cons of each practice management solution. Buy the Private Practice Paperwork Packet. TherapyNotes, LLC All business procedures involving documentation should follow the set best practices. This is to make data entry tracking easier. : Since the records submitted as evidence of compliance dont identify the person responsible for creating them, the business is having difficulty finding more information on their compliance data. Your practice's Document Library is easily accessible from the main navigation menu at the top of every page in TherapyNotes - simply click onLibraryat the top of your screen to view the documents that are available to users in your practice. Customize any template to suit your needs and preferences or start using it immediately after downloading. Corrections can only be done when all of the documents stakeholders have been informed and the Quality Assurance (QA) Lead has given the correction a go-signal. Follow the ALCOA principles that make up data integrity and are the cornerstone of good documentation practices. Some therapists also include things such as expectations for contacting the therapist after hours, no show policy and fees. For each name and signature added to the template, you also have the option to put in the following details: Erick Brent Francisco is a content writer and researcher for SafetyCulture since 2018. In this guide, we'll cover: Consent documents Editing an existing consent document Adding a new consent document Setting consent documents as default Intake forms Creating new intake forms Paperless Intakes - SimplePractice EHR Software for Health & Wellness Professionals | SimplePractice If the document is handwritten, cross out the error so that its still legible. Get answers to the following questions: What do you mean by good documentation? For example, if you specialize in working with clients with chronic pain/illness, you likely want to have detailed questions related to medical history and contact information for the clients primary care physician. I have a PDF document that I want to upload to Simple Practice so that I can send it with my Intake Forms to new clients? In some circumstances, you may work with other professionals (physician, previous therapist) to provide better treatment for your client. It should be easy to trace information to its source, though ideally the author or the person who recorded the data should be immediately identifiable or named in the document. Though data cannot be edited, any errors in the data can be corrected, provided that the person who recorded the data is the one correcting the error. Provide explanations for complex information when possible. Where do I find my consent documents and intake forms? Social media is pervasive and the likelihood of possible ethical conflicts is now inherent in our work as counselors. PDF SAMPLE FORM OF HIPAA NOTICE OF PRIVACY PRACTICES - southernute-nsn.gov Document Library - TherapyNotes Help Center Make sure to review with your client the limits to their confidentiality in these circumstances and have a release form that outlines to whom youll be speaking, for what purpose, and for what time frame. Each letter in the ALCOA acronym corresponds to a characteristic of good data. Will I receive a tax Form 1099-K? Just get a template in the beginning and you can adjust it to your needs. SimplePractice Secure Client Portal Software They are unable to answer the regulatory authoritys follow-up questions and are in danger of being deemed as non-compliant by the regulatory authority. Maelisa Hall, PsyD is a clinical psychologist who teaches therapists how to create rock-solid documentation so they can spend more time with their clients and less time worrying about paperwork. Documents should have the following dates: All dates must be accurate. Type of information: Procedural documents. Our therapy resources have helped thousands of your peers get better at their jobs. When correcting an error, do not block or erase the error. Starting up a counseling practice isnt actually that difficult- maybe you pick a name, get a business license and open a business bank account, order some business cards, sub-lease from a colleague and get a phone number. You may also work with a significant other (spouse, child, parent). These can be added at any time, and there's no limit to how many can be added. Users added to your SafetyCulture account, whether on desktop or mobile, will see the latest version of documents they have access to. The idea here is that your clients record is just that- their record, not yours. This site uses Akismet to reduce spam. The type of intake assessment you use depends on the services you provide, your treatment modality and your niche. How To Talk To Your Kids About Coronavirus (COVID-19), Niching Up: The Narrower the Market, the Bigger the Prize with Chris Dreyer | POP 886, Speak To Your Target Audience Through Your Website with Camille McDaniel, LPC | GP 178, How to start a private practice: A 28-step checklist | POP 885, How Your Office Space is the Packaging for Your Practice with Interior Designer, Carolyn Boldt | POP 884, 10 Questions to Ask When Choosing a Biller In Private Practice. Conduct strategic and high-impact performance improvements; Optimize resource allocation and developmental planning; and. The first set of good documentation practices examples illustrates their importance and why you should follow them. If your specialty is counseling couples with a history of infidelity youll focus more on family history and couples-specific questions. What is it: Accurate means that data can be relied upon to be true, valid, and correct. Your excitement is suddenly overshadowed by terror- Do I have all the right forms? Click the Upload File button within the Library Files tab to add documents for the rest of your staff to see. Scenario: A regulatory authority has some follow-up questions for a business that recently submitted evidence of its compliance with a regulation. Before you begin implementing good documentation practices: If youve decided that your existing documents dont need to follow good documentation practices or if youve already done the required steps to apply good documentation practices to existing documents, then you can begin the implementation of the following: Digitize the way you workEliminate manual tasks and streamline your operations.Get started for free. If you keep a credit card on file to charge your clients for no shows or any other reason, youll want to review that policy with them. Scenario: Not Followed: Since the SOP is handwritten and the authors handwriting is difficult to read, the employee merely guesses what some steps in the SOP are. Documentation - SimplePractice Support You dont need to get their signatures in-person. Regularly check (at least every 6 months) if people across your business are following good documentation practices and if the created documents reflect that. She has a free Private Practice Paperwork Crash Course available here. You as the therapist keep it updated and safe and make sure your clients know how youre doing that. I recommend having a form because it clearly outlines your guidelines. SafetyCulture is free to download as a web-based software and as a mobile app. Buy the Private Practice Paperwork Packet. It aims to preserve the data integrity of important documents and records and can also serve as guidelines for how to record information and store data appropriately. Get the #1 HIPAA-compliant EHR and practice management software. This could be a simple sentence or two in your progress note or it could be a one-page template with goals, treatment recommendations, and outcomes. Practice Administrators can also enable or disableany form from being able to be shared on the client portal, preventing users from accidentally sending it to a patient. Even outside of the pharmaceutical and manufacturing industries, information stored in documents and records, as well as maintaining proper records lifecycle practices, is critical to the functioning of your business. What is it: Original means that data, once recorded, cannot be edited, altered, or erased. Some of these will depend on the specifics of your practice or even your clientele but well review the basics. SimplePractice Software Reviews & Ratings | 2023 | Software Advice If a document is added to the Document Library and eligible for portal sharing, practice users are able to send the document to a client through TherapyPortal for the client to review, electronically sign, or complete and send back to the practice. : Since the business immediately knows who recorded the compliance data, they are able to ask that person for more information and even have them answer the follow-up questions of the regulatory authority directly. Each document must have an author. Make good documentation practices part of employees day-to-day routine. There should be no shared passwords or shared data system log-ins. For more information, read How To: Edit, Archive, and Delete Practice Documents. To find out more, read our updated Privacy Policy. SafetyCulture has a public library of 80,000+ free templates on a variety of use cases. The Library is organized into two tabs: Library Files and Portal Forms. There should be a documented reason for each corrected error. Data is incredibly powerful and good data allows you to: But how do you get these benefits? The SimplePracticeClient Portal is a secure and SECTIONS: easy way for you to communicate with your clinician, request appointments, sign documents, and even pay your appointment fees. This is to verify that the person identified as the author in the document is actually the one who recorded the data. Starting Your Paperwork Off Right in Private Practice No pre-dating (documented date is before actual date) or post-dating (documented date is after actual date). Updated Adding assessments, diagnoses, and treatment plans Jazmine 21 hours ago Updated Assessments, diagnoses and treatment plans, and mental status exams are documentation that can be added to a client's file without being tied to a specific date of service. Uploading documents. : A regulatory authority has some follow-up questions for a business that recently submitted evidence of its compliance with a regulation. Choose a popular template such as DAP (Data, Assessment, Plan) or SOAP (Subjective, Objective, Assessment, Plan) and be sure documentation is part of your regular schedule so you stay up to date. Billing insurance can take up, Innovative ideas to start, grow, and scale your private practice, Shannon Heers: From One Group Practice Boss to Another, Nadyne Busichios Next Level Practice Journey, One Year Practice Plan (Starting a Practice), Next Level Practice Community (Starting a Practice), Group Practice Launch (Starting a Group Practice), Buy the Private Practice Paperwork Packet. Scenario: An employee has to contact a customer to inform them that the specific item they wanted to purchase before is now in stock.