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Clinical Documentation 101

A training by Shalyn Rose, LCSW


Let's face it, jotting down notes isn't what we imagined doing when we dreamed of becoming clinicians. We're trained in clinical theories, diagnosis, and interventions – not paperwork. Yet, here we are in private practice, often unsure about the best way to document our work. It's crucial, especially if you work with insurance companies. Proper notes are key to

passing audits and keeping your earnings secure!

This course will teach you the basics of creating and maintaining high-quality, compliant and accurate medical records. You will learn how to document various clinical scenarios, how to use different types of documentation and how to follow the

best practices of documentation. Suitable for anyone who works in health care, whether you are new to clinical

documentation or just want to refresh your skills and knowledge. Don't miss this opportunity to enhance your

documentation skills and take your career to the next level.

Upcoming Dates

Wednesday, June 12, 2024

9am-12pm (EST)

All trainings will be conducted virtually using Google Meet as the platform.

In-Person Training

Friday, August 9th 2024


Women's Consortium

2321 Whitney Ave #401, Hamden, CT 06518

Registration Information Coming Soon 


*You will receive an email with the Google Meet link and the training materials one day before the training date.

Intended Audience

Our training program is NASW-approved and offers 3 CEUs for LCSWs, LPCs, LMFTs, LMSWs, LPC-As, and PsyDs for Connecticut Licensed Clinicians.

Virtual Team Meeting
Book Stack

Interactive Coursework

  • Examples of measurable vs. non measurable treatment plan objectives

  • A list of clinical terms, phrases, and language to refer to when writing notes

  • Growing list of Q&A's from participants

  • Audit tool to review your own documentation

  • Checklist to refer to when documenting

  • Insider information on the process and outcome of a Medicaid audit 

  • Examples of a biopsychosocial, progress note, and treatment plan/update, from a real client's chart using a SOAP template

  • Takeaway PowerPoint

Learning Objectives

  • Master the art of composing progress notes, treatment plans, assessments, and discharge plans that align with insurance criteria.

  • Streamline the note-writing process to save valuable time.

  • Recognize potential warning signs that could prompt an insurance audit.

  • Acquire knowledge on the appropriate actions to take if you undergo an audit.

Speaking at Seminar
Training course

Group Doc Training

Attention Practice Owners:

Insurance companies are very strict about documentation. They can audit private practices at any time and make owners pay back thousands of dollars if they are not satisfied with notes. 

If you’re considering hosting training sessions for your team of clinicians or prescribers, whether onsite or virtually, please reach out. We offer discounted group rates tailored to the specific needs of your practice.

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