MRI is a Non-profit Organization
Supporting Therapists Since 1997
Donations Appreciated

Audit Proof Ethical Charting

This comprehensive no-cost course and practice with no-cost version of The GRID, an adaptable-template software, will resolve your documentation fears while you learn to audit proof your practice.

Ethical, legal and comprehensive charting require that psychotherapists understand complex requirements. Charting requirements are based on State and Federal regulations, contract law, and standards of care for psychotherapy practice. Healthplans, auditors, licensing boards and courts of law do have not uniform expectations about charting, but those entities can request access to psychotherapy charts. Payers use internal or external auditors who set their own requirements. You need to know what these entities have the right to view.

Professional associations, licensing boards and attorneys advise practitioners to “obtain training” and “seek consultation” concerning documentation requirements. Unfortunately training courses about charting typically instill fear while they offer no efficient or reliable methods to resolve the fear. Most charting templates, paper or electronic, offer no guidelines about what’s required, and what should be avoided when charting. Attorneys may tell you to “document everything.” Attorneys do not acknowledge there are “minimum medically necessary” requirements for charted information; and, people become upset if personal, sensitive or private information appears in their chart, especially if it has no bearing on their treatment.

Brief Introduction and Overview of Course

Step 1 - Download The GRID Learn While You Chart Software (FREE)

Software Total Cost: No-cost version (unlimited use)

Download and Install The GRID Software: The no-cost version will save in your download folder. You must install the software on you local computer.

To install The GRID software you must download the SetUp program to your computer’s hard drive.

1. DOWNLOAD LINK The download should take about 20 seconds.

2. Locate the SetUp program in your download folder after the down load is complete.
   The SetUp program is GRID_Charting_SetUp_9.0.4.msi

3. Click on the GRID Charting SetUp program in your download folder to install The GRID.Go to your download folder. Run (click on) the file named GRID_Charting_SetUp. Follow the instructions.

Note: This download is a no-cost training version. You can download it one time on your computer. Do not attempt to download and install the software more than one time. The second attempt will cause an error that requires technical support to fix and that support is not available for the no-cost version. You can obtain a supported version by clicking in the Help tab in the The GRID and selecting “update/purchase”.

Description: The GRID software is designed to provide continuous learning to you while you chart. The structure and functionality of the software will demonstrate the structure and logic of chartnotes, what medical necessity looks like, how to meet minimum necessary information requirements, and ways to rapidly create chart notes that patients and physicians will find useful and easy to understand.

Step 2 - Register for Training

CE Total Cost: No cost

CE Hours: 3 hours (1 hour ethics CE included)

To earn 3 hours of CE you must Register for the Training, install the No-Cost training version of The GRID Learn While You Chart software, and successfully complete a brief comprehension test at the end of the course.

4 COURSE RECOMMNEDATIONS

1. Read the MRI published articles:

   • What is the Value of Charting in Psychotherapy Practice?

   • Psychotherapy Charting-by-Exception (CBE) in Private Practice

2. Watch the audio-video program.

3. Use The GRID software to reinforce how to ethically audit proof your chart notes.

4. Pass test to demonstrate mastery of information presented in the articles, The GRID training software, and the audio-video presentation.

   CE Certificate issued upon completion. Participants will have access to all course material for one year and be able to continue their practice with their trial training version of the GRID software.

Participants will be able to:

1. Identify the information an auditor is and is not entitled to probe for.

2. Describe the differences between “medical records” a “designated record set” and “psychotherapy notes”.

3. Document medical necessity, using “minimum necessary information.”

4. Document the categories of information necessary to justify services.

5. Document chart notes that meet ethical, legal, contractual and clinical requirements.

6. Describe the practical and evidence-based value of charting

While you create chart notes, The GRID Chart While You Learn teaches essential elements of what you need to chart legally, ethically, appropriately.

• Create a treatment plan and 30 progress notes in 30 to 60 minutes.

• Create, view, edit and amend all chart notes for a case on one screen.

• “While you chart” training and feedback offers color coded reminders which direct attention to charting requirements and quality.

• The GRID’s Self-Audit feature lets you examine chart notes or an entire record, and displays feedback about 16 quality and completeness measures that matter to auditors.

  MRI is a Non-profit Organization

  Supporting Therapists Since 1997

  Donations Appreciated

  (Click here to Donate)

Instructors

Michael Conner, PsyD (lead instructor)

An engineer and psychologist, Dr. Conner practices clinical, family and medical psychology. Dr. Conner is expert in crisis intervention, emergency psychiatric services, dangerous behavior, residential treatment and outdoor behavioral health. He provides professional training in psychotherapy charting, auditing, ethics, crisis intervention, dangerousness, parenting and other mental health topics.

In 1989, Dr. Conner began pioneering research in the use of computers in personality assessment and training. This included the development and operation of computer-based test interpretation and associated ethical issues. He developed a computer-based mental health screening tool for primary medical care at Kaiser Permanente. This system accurately evaluated and recommended medications based on the decisions processes of psychiatrists. Other projects included Internet-based screening questionnaires for adolescents at risk. Dr. He is the creator of The GRID Learn While You Chart software system offered in this training.

Michaele Dunlap, PsyD

Michaele Dunlap, PsyD began practice as a Masters’ level professional in 1985. She was licensed as a psychologist in 1991. She practices at Mentor Professional Corporation, formed in 1992 to support supervision for new psychologists and facilitate professional collaboration. Her clinical focus is on adults, couples, and families; She works with addictions, trauma recovery, life and health challenges, personal and relationship growth. She consults regarding relationship difficulties in closely held businesses, provides consultation to mental health professionals, and to human services organizations.

Dr. Dunlap has organized continuing education events for mental health professionals since 1989. She has been a presenter at numerous continuing education events. Her presentation topics have included: Clinical records keeping; Jane Loevinger’s Theory of Ego Development; the MRI ConnectingCare model; Aspects of psychologists self-care; Dealing with managed care; Oregon’s Duty to Report law; Risks of disclosure in mental health services; Ethical practice in mental health; Identifying and dealing with nightmare clinical situations; The pragmatics of dealing with HIPAA regulations; Women’s chemical dependence and recovery; Internet marketing for mental health professionals; and mental health private practice development.