Documenting Medical Necessity: Clinical Documentation and Treatment Planning

Every note you write is read by people who were never in the room: the next clinician, a utilization reviewer, an auditor. This course teaches you to document so that each of them can see exactly what you saw, what you decided, and why care is necessary.

You’ll follow one client, Alexis, from her first session to a complete record: the intake and biopsychosocial, a differential diagnosis with documented rule-outs, a measurable treatment plan, and progress notes that keep the golden thread unbroken. In the final module you’ll read that record through the eyes of managed care, New York Medicaid, and Medicare, and meet a second client, Walter, to practice Medicare-ready documentation.

The course includes four narrated video modules, a fillable Learner Workbook with 15 hands-on exercises and sample answers, and ready-to-use Lighthouse templates for your own practice.

Lighthouse Mental Health Counseling Services, PLLC is recognized by the New York State Education Department’s State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors. #MHC-0287. This is a self-study course; NYSED allows up to 12 of the 36 required hours in each three-year registration period to be self-study.