Full Course Description

Mental Health Documentation & Medical Necessity: Simple, Clear Guidelines that Maintain Quality of Care and Protect Your Practice

“I love paperwork!”.

--Said NO clinician, EVER

Yet, the success of your practice depends on your ability to write good intake summaries, treatment plans, session notes, case/collateral notes, and discharge summaries. Taken together, these pieces to the documentation puzzle support your goal of providing quality services to your clients. They also impact the stability and success of your practice. When done well, they result in piece of mind and timely payment from insurance companies. When done poorly, they lead to the misery of denials, audits, and lost income.

The great news is that you CAN become proficient at mental health documentation and medical necessity. This seminar provides clear and simple guidelines for recordkeeping that adheres to professional standards and ethical codes, supports delivery of quality care, and reduces errors and delays in payments.

You will receive expert instruction from Beth Rontal, LICSW, affectionally known as the Documentation Wizard. For over 15 years, Beth has been instrumental at changing how individuals and organizations approach documentation. The results speak for themselves. Rates at which paperwork was returned to clinicians for correction have dropped significantly, in one case from 65% to under 8%. This gave clinicians back 3 to 5 clinical hours per week, saving thousands of dollars and improving job satisfaction.

Program Information


  1. Determine the importance of proper documentation in informing clinical decision-making.
  2. Evaluate the role of the clinical diagnosis in justifying medical necessity and providing more effective services to clients.
  3. Determine how to use the behavioral language required by insurance companies to facilitate delivery of services to clients.
  4. Assess how to document what really happens in a clinical session without violating privacy or confidentiality.
  5. Assess medical necessity by employing the “golden thread” for improved treatment outcomes.
  6. Analyze potential red flags in documentation and the proper corrective measures for them


Get Past Your Negative Feelings About Documentation

  • Documentation as a contributor to good clinical work
  • Documentation through the lens of the “Golden Thread”
  • Documentation as a protector of income and integrity
  • Anxiety-reducing answers to common questions
Embrace the Requirement of Medical Necessity
  • The elements of medical necessity
  • The “Golden Thread” as a key part of medical necessity
  • Establish the connection between diagnosis and treatment
How to Write:
  • The Diagnostic Summary
    • What’s needed in the diagnostic summary, and why
    • How the diagnostic summary initiates the path of the Golden Thread
  • The Treatment Plan
    • What’s needed in a treatment plan, and why
    • Operationalize the presenting problem
      • Questions to ask
      • Describe the diagnostic criteria in behavioral terms
    • Make a clear connection between goals, objectives, and interventions
    • Protect the client and the therapist with a thoughtful risk assessment
    • Evaluate client progress
    • How the treatment plan it continues the path of the Golden Thread
    • And more …
    • Activity: Write a treatment plan
  • The Session Note
    • The session’s note relationship to the treatment plan
    • What’s needed in a session note and why
    • Descriptive or narrative approach to interventions used
    • Changes to treatment plan
    • Justify multiple sessions
    • Activity: Write a session note
  • The Case and Collateral Contact Note
    • What’s needed in a case and collateral contact note and why
    • Differences between case and collateral contact notes
    • Provide a clinical justification for the case/collateral consult
  • The Discharge Summary
    • What’s needed in a discharge summary, and why
    • How the discharge summary completes the Golden Thread

Target Audience

  • Mental Health Administrators
  • Marriage and Family Therapists
  • Physicians
  • Psychiatrists
  • Psychologists
  • Counselors
  • Social Workers
  • Office Managers
  • Mental Health Nurses
  • Addiction Counselors
  • Nurses
  • Other Mental Health Professionals

Copyright : 08/06/2021

Mastering Differential Diagnosis with the DSM-5-TR™: A System-Based Approach

A recent study found that more than a third of all diagnoses assigned to individuals with severe mental disorders include errors, and over half of clients with major depressive disorders are incorrectly diagnosed. Such errors in diagnosis can greatly harm clients by preventing them from receiving proper treatment. Fortunately, most of these errors are easily preventable in the first place, and that’s where the DSM-5-TR and this webinar can help!

Using a differential diagnosis process with every client and applying the updated diagnostic criteria sets and specifiers for mental disorders in the DSM-5-TR, the latest version of the DSM manual, will improve the professionals’ accuracy in diagnosis and help prevent missed diagnoses.

This advanced seminar is designed specifically for mental health professionals seeking to master clinical differential diagnosis using the DSM-5-TR, the ICD-10 and online assessment tools. Case examples and studies are provided throughout - giving you the opportunity to learn and practice a symptoms-based, four-step diagnostic method. In this workshop you will also learn:

  • Key symptoms for each diagnosis
  • Common differential diagnoses
  • DSM-5-TR additions to the DSM-5
  • Frequent comorbid disorders of anxiety, depressive, trauma-related, substance-related, psychotic, and neurodevelopmental disorders
  • How to conduct an effective diagnostic intake interview
  • Online assessment tools to narrow diagnosis and potential comorbidities

Get caught up with the latest diagnoses and codes in the new DSM-5-TR!

Don’t forget to have your DSM-5-TR manual handy!

Program Information


  1. Describe the new additions and revisions in the DSM-5-TR impacting diagnosis of mental disorders.  
  2. Conduct a four-step diagnostic process to accurately identify and code a client’s diagnosis.
  3. Investigate common differential DSM-5-TR diagnoses for clients with anxiety, depressive, or abnormal cognitive symptoms.
  4. Differentiate between overlapping symptoms and comorbid conditions in order to provide the correct diagnosis.
  5. Analyze differential diagnoses for clients who present with disruptive behavior.
  6. Collect the specific information required for an accurate differential DSM-5-TR diagnosis of clients with a history of trauma. 
  7. Utilize the DSM-5-TR severity tables, assessment tools, and coding notes to improve the accuracy of diagnosis and ICD-10 coding.


DSM-5-TR Changes and Additions

  • Why a revision to the DSM-5? 
    • Significant advances in understanding specific disorders
    • Knowledge of the impact of racism on diagnosis and presenting symptoms
    • Alignment with the ICD-11 disorder names and codes
  • Key diagnostic changes 
    • Prolonged Grief Disorder, Suicidal Behavior, Nonsuicidal Self-Injury
    • Changed diagnostic criteria-sets for over 70 mental disorders
    • New names for disorders and symptoms
    • New mental disorder subtypes and specifiers
    • Revised text for all most all disorders and increased emphasis on the impact of racism and discrimination in diagnosis
    • Revised ICD-10-CM codes 
Brief Review of Diagnosis using the DSM-5-TR and ICD-10-CM
  • Using the DSM-5-TR Manual for diagnosis and ICD-10 coding and recording 
  • Web-based DSM-5 resources
Four Step Differential Diagnosis Method
  • Effective intake interview strategies
  • Identify Cognitive, Affective, and Behavioral DSM-5-TR symptom clusters
  • Compile an accurate and comprehensive differential diagnosis list
  • Determining the initial DSM-5-TR diagnosis list
  • Identifying Comorbid Disorders
DSM-5-TR Diagnoses with Common Presenting Symptoms 
  • Mental Disorders with symptoms of Depression, Anxiety, and Psychosis 
    • Differentiating Depressive Disorders
    • Normal Grief versus DSM-5-TR Prolonged Grief Disorder  
    • Differentiating Anxiety Disorders 
    • Psychosis, patterns of cognitive symptoms, and cognitive deficits
    • Mental Disorders on the Schizophrenia Spectrum versus Bipolar Disorders
    • Substances and Medical Conditions associated with psychological symptoms
    • Effectively differentiate overlapping disorders and identify comorbid conditions
Differential Diagnoses of Clients with Dysfunctional Behaviors 
  • Clients with symptoms associated with experiences of Trauma control
    • DSM-5-TR Trauma and Stressor-Related Mental Disorders 
    • Differential Diagnosis of Mental Disorders Developing after Stressors
  • Clients with Impulsive Behaviors or Poor Impulse Control
    • Normal development of self-regulation and its implications in children and adults with impulse control problems
    • Substance-Related and Medical Conditions that Impact Impulse Regulation 
    • DSM-5-TR Disorders with Dominant Disruptive and Impulse Control symptoms  
Diagnosis Challenge Cases
  • Case 1: Client with multiple problems 
  • Case 2: A sad, overwhelmed client
  • Case 3: Fearful and worried client
  • Case 4: Out-of-control and angry adolescent 

Target Audience

  • Counselors
  • Social Workers
  • Psychologists
  • Physicians
  • Case Managers
  • Addiction Counselors
  • Therapists
  • Marriage & Family Therapists 
  • Nurses
  • Nurse Practitioners
  • Other Mental Health Professionals

Copyright : 10/03/2022

Differential Diagnosis Challenges: Clients with Trauma, Self-Injury, Impulsivity and Other Complex Behaviors

Take your DSM-5® diagnostic skills to the next level! This seminar is designed specifically for mental health professionals seeking to master clinical diagnosis and differential diagnosis using the DSM-5®, ICD-10 and online assessment tools. The focus of this workshop is on the key symptoms for each diagnosis, common differential diagnoses and frequent comorbid disorders.

Case examples and studies are provided throughout - giving you the opportunity to learn and apply a four-step symptoms-based diagnostic method. Topics include the clinical intake interview, differential diagnoses, online assessment tools to narrow diagnosis and potential comorbidities.

Program Information


  1. Clients with Impulsive Behaviors and Weak Impulse Control
  1. Symptoms of impulsivity/diminished impulse-control
  1. Child
  2. Adolescent and Adult
  1. Diagnostic Challenge: Case 8 Wyatt
  2. Substance-related and medical conditions associated with impulse-control problems
  3. Mental Disorders with impulsivity as one of the criteria symptom clusters
  4. Frequent Comorbid Disorders
  1. Clients with Experiences of Trauma or Psychosocial Stress
  1. Definition of Trauma in DSM-5
  2. Case Study 9: Annemarie
  3. Necessary information about the trauma event(s)
  4. The role of Substance-Related and Medical conditions and Trauma
  5. Differential Diagnosis: Trauma-Related?

a. Mental Disorders that follow traumatic event

b. Mental Disorders that follow severe neglect before age of 5

  1. Differential Diagnosis: Does not meet diagnostic criteria set for PTSD
  1. Adjustment Disorder or Other Mental Disorder
  2. Other Specified Trauma Related Disorder
  1. Frequent Comorbid Disorders


  1. Clients with Suicidal Ideation or Behaviors
  1. Clusters of Suicidal Symptoms
  2. Differential Diagnosis of the Underlying Mental Disorder
  1. Mental Disorders associated with Suicidal Capability
  2. Mental Disorders associated with Suicidal Ideation
  1. Medications that enhance suicidal risk
  2. Diagnostic Challenge: Case 10 Marty


  1. Clients with Self-Injury Behaviors
  1. Understanding self-injury, non-suicidal behaviors
  2. Substance Use Disorders that induce self-injury behaviors
  3. Mental Disorders associated with self-injury
  1. Client states motivation for the self-injurious behavior
  2. No apparent reason for the self-injurious behavior


  1. Wrap Up Diagnosis Challege: Case Study 11 Joe Jensen
  1. Working the Differential Diagnosis Process
  2. What About Personality Disorder?
  3. Joe’s initial DSM-5 diagnosis


1. Evaluate client syndromes of poor impulse control, suicidal ideation, suicidal capability, intentional self-injury and symptoms following traumatic experiences.

2. Apply a four-step differential diagnostic method to diagnose the underlying mental disorders of clients with dysfunctional behavioral patterns and/or a history of trauma.

3. Collect the specific information required for an accurate differential DSM-5 diagnosis of clients with a history of trauma.

4. Conduct a differential diagnosis for clients with impulsive, suicidal and self-injurious behaviors.

Target Audience

Addiction Counselors, Counselors, Marriage & Family Therapists, Nurses, Psychologists, Social Workers, and other Mental Health Professionals

Copyright : 05/02/2019

Comprehensive DSM-5-TR™ Updates: New Diagnoses, Coding Changes & Cultural Considerations

Neglecting new diagnoses, making coding errors & culturally insensitive language faux pas can be time-consuming, frustrating & cause you to lose clients.

But… it doesn’t have to be that way.  Quickly and efficiently learn the updates to DSM-5-TR™!

Join Dr. George Haarman, PSYD, LMFT for the most thorough and comprehensive education you can get on DSM-5-TR™ updates.  You’ll get everything you need to know on:

  • New disorders including prolonged grief, suicidal behavior disorder & more! 
  • Specific suicidal considerations for EVERY disorder 
  • Updated language for gender dysphoria, dysthymia, delirium & more 
  • How to apply over 50 coding changes and new V-code specifiers

Plus, explore cultural considerations, broad DSM controversies, philosophy, unethical practices & more!  

Register now!

Program Information


  1. Inspect differences between the DSM-5® and the DSM-5-TR™.
  2. Categorize new classifications that have been added to the DSM-5-TR™.
  3. Appraise the impact of culture and race on DSM-5-TR™.
  4. Apply updates to coding changes to over 50 changes. 
  5. Integrate changes in diagnostic criteria between DSM-5® and DSM-5-TR™.
  6. Analyze diagnostic criteria for Suicidal Behavior Disorder, Non-Suicidal Self-Injury, and Prolonged Grief Disorder.


DSM-5-TR™: Controversies & Philosophy 

  • “Colossal errors” in the DSM-5™
  • Ties to the pharmaceutical industry & what it means 
  • Have we pathologized everyone?
  • Internalizing vs externalizing components of disorders
  • Integrate WHODAS in assessment
  • Culture free or impacted by creators?
Disorder & Diagnostic Criteria Changes
  • Updates to:
    • Dysthymia 
    • Gender Dysphoria – changes to language
    • Delirium
    • Adjustment Disorders
    • Specific instructions coding substance use disorder specifiers 
    • Expirations of grief – have we pathologized it?
  • Major differences between DSM-5™ & DSM-5-TR™
Master Coding Changes
  • Over 50 coding changes, NEW:
    • Specifiers
    • V-Codes
    • Z-Codes
  • Language updates & more
Cultural Considerations: Essential Diagnoses
  • Use the Cultural formation interview (CFI)
  • Susto, Taijin Kyofusho & more cultural diagnoses 
  • Non-diagnostic foci of clinical attention
Unethical Practices & Common Questions
  • Going too far with Adjustment Disorders?
  • Suicide considerations for EVERY disorder
  • Pocket guide vs Full 
  • When do I withhold diagnosis?
  • Can I skip a medical examination or screening?
  • What if I just work with one population?

Target Audience

  • Counselors
  • Social Workers
  • Psychologists
  • Physicians
  • Physician Assistants
  • Case Managers
  • Addiction Counselors
  • Therapists
  • Marriage & Family Therapists
  • Nurses
  • Nurse Practitioners
  • Other Mental Health Professionals

Copyright : 05/16/2022