About this course

Learning Objectives

• Describe how diagnosis, symptoms, functional impairment, and treatment goals work together to demonstrate medical necessity in psychotherapy documentation.
• Identify key clinical elements that strengthen the quality, clarity, and clinical relevance of progress notes.
• Apply documentation best practices to revise a vague progress note into a concise, objective, and clinically relevant note.

Learning Levels

• Beginner, all levels are welcomed

Target Audience

Course Instructor(s)

• 

  Erena DiGonis, LCSW-R

  Trauma Therapist, Educator, and Founder of EngagedMinds Continuing Education

  Erena DiGonis, LCSW-R, is a New York State Licensed Clinical Social Worker, Certified Health Coach, and Certified Clinical Anxiety and Trauma Treatment Professional. She is also a Certified Brainspotting Therapist and has advanced training in EMDR and Pain Reprocessing Therapy. Erena has more than twenty-three years of clinical and professional experience as a therapist, educator, supervisor, and consultant. Throughout her career, she has worked in community mental health, psychiatric, residential, in-home, and private practice settings, providing care for hundreds of individuals with complex mental health needs.

  Erena's expertise extends beyond direct clinical practice. As Assistant Director of Quality Improvement for multiple behavioral health programs, she was responsible for clinical documentation audits, treatment plan reviews, quality improvement initiatives, policy development, regulatory investigations, and preparing programs for reviews and surveys by the New York State Office of Mental Health (OMH), Office for People With Developmental Disabilities (OPWDD), New York State Department of Health (DOH), the Centers for Medicare & Medicaid Services (CMS), and the Council on Accreditation (COA). This experience allows her to teach documentation and ethics through both a clinician's and an auditor's lens, helping professionals create records that are clinically meaningful, ethically sound, compliant with regulatory expectations, and audit-ready.

  Erena is the Founder and Continuing Education Director of EngagedMinds, a national continuing education organization providing evidence-informed training for social workers, counselors, therapists, and psychologists. She is a sought-after writer, speaker, and consultant whose work has been featured in Cosmopolitan, Marie Claire, Psychology Today, Reader's Digest, Women's Health, and MEL Magazine. She has served as a reviewer for the National Association of Social Workers (NASW) Press and is an Advisory Board Member for the CPTSD Foundation.

Disclosure

References

• American Psychological Association. (2007). Record keeping guidelines. American Psychologist, 62(9), 993–1004. https://doi.org/10.1037/0003-066X.62.9.993
• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association Publishing.
• Centers for Medicare & Medicaid Services. (2018). Medicaid Integrity Education: Medical Professional Fact Sheet. Retrieved from hops://www.cms.gov/Medicare-Medicaid-Coordina=on/Fraud-Preven=on/MedicaidIntegrity-Educa=on/Downloads/docmaoers-medicalprof-factsheet.pdf
• Centers for Medicare & Medicaid Services. (2024). Medicaid documentation for behavioral health practitioners. U.S. Department of Health and Human Services.
• de Jong, K., Conijn, J. M., Gallagher, R. A. V., Reshetnikova, A. S., Heij, M., & Lutz, M. C. (2023). Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: A multilevel meta-analysis. Clinical Psychology Review, 101, 102262.
• Gold, L. H. (2014). DSM-5 and the assessment of functioning: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Journal of the American Academy of Psychiatry and the Law, 42(2), 173–181
• Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
• Meridian Health Plan. (2024). Behavioral health treatment documentation requirements (Clinical Policy CP.BH.500).
• National Association of Social Workers. (2021). Code of Ethics of the National Association of Social Workers. National Association of Social Workers.
• Schwarz, J., Bärkås, A., Blease, C., Collins, L., Hägglund, M., Markham, S., & Hochwarter, S. (2021). Sharing Clinical Notes and Electronic Health Records With People Affected by Mental Health Conditions: Scoping Review. JMIR mental health, 8(12), e34170. https://doi.org/10.2196/34170
• Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097.
• Stanhope, V., Tondora, J., Yoo, N., Marcus, S. C., & Solomon, P. (2024). The impact of collaborative documentation on person-centered care in behavioral health settings. Psychiatric Services, 75(9), 1021–1028.
• Syed, S. A., Eth, S., Fontenele, R., & Regan, J. (2024). Access to psychotherapy notes: Review of legal standards for mental health clinicians. American Journal of Psychotherapy, 77(4).
• Yoo, N., Stanhope, V., Tondora, J., & Marcus, S. C. (2024). Impact of collaborative documentation on completeness and person-centeredness of community mental health visit notes. Psychiatric Services, 75(8), 905–912.
• Wang, X., Zhou, Y., & Zhou, G. (2025). The Application and Ethical Implication of Generative AI in Mental Health: Systematic Review. JMIR mental health, 12, e70610. https://doi.org/10.2196/70610
• Wiger, D. E. (2021). The psychotherapy documentation primer (4th ed.). John Wiley & Sons.
• Wilkinson D. J. (2023). What is 'medical necessity'?. Clinical ethics, 18(3), 285–286. https://doi.org/10.1177/14777509231190521