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Please note: Because access to our protected content is provided immediately upon signing up for an on-demand program, refunds are not available.
Defensive Documentation: The Laws & Ethics of Advocating & Protecting Our Clients through Clinical Notes
Defensive Documentation: The Laws & Ethics of Advocating for & Protecting Our Clients through Clinical Notes (on-demand)
- Intended for: Novice/Beginning Learners: No advance knowledge required
- Content/curriculum: The entire curriculum is focused on law & ethics
- NBCC Content Area: Counselor Professional Identity and Practice Issues
- CE hours available: 2
Program Description
How can mental health professionals appropriately comply with the requirements of health insurance plans in documenting medical necessity for psychotherapy treatment while also protecting clients holding vulnerable identities from being exposed to possible governmental intrusion into their lives?
The Code of Ethics of the American Counseling Association clearly states that counselors have a duty to avoid harming their clients, and to advocate on behalf of clients to address potential barriers that inhibit access or the growth and development of clients. This two-hour, 2-CE workshop is designed for practicing counselors, social workers, marriage and family therapists, and other mental health professionals who are concerned about the rapidly changing macro environment in the United States which may put clients at risk of harm, and who want to be proactive in adopting client-centered, protective practices of care in their documentation.
This training covers of-the-moment recommendations backed by legal and ethical standards for documenting psychotherapy for:
- trans, nonbinary, gender nonconforming, and gender questioning clients
- queer, gay, lesbian, and other non-hetero identifying clients
- clients with an immigration background or in families and communities of immigrants
- neurodivergent and otherwise non-neurotypical clients
- clients experiencing pregnancy
The practices presented can be adapted for clients of other non-dominant social identities as well.
Educational Goals
This training will cover legal and ethical aspects to clinical documentation, including best practices for documenting medical necessity, and considerations for protecting sensitive client information under HIPAA and state laws. An overview of the current legal and regulatory environment for protected identities and medical records in the Medicaid and Medicare systems of a sampling of states, including California, Florida, and Texas, will be provided.
Learning Objectives
Upon completion of this program, participants will be able to:
- Describe the purpose, ownership, and legal considerations of clinical notes for mental health treatment.
- Define the concept of medical necessity in the context of clinical notes for mental health counseling and psychotherapy.
- Identify client and session data elements that, if included in notes or a file, would cause it to be considered a “medical record”
- Discuss at least 2 ethical strategies for clinical documentation that may help protect vulnerable client information in 2025.
Equity Focus
This training is centered on protecting clients who may be vulnerable based on marginalized identities that they hold.
Presenters
Presenter Name: Lisa Wenninger, PhD, MBA, LPCC, LMHC, NCC, BC-TMH (she/her)
Dr. Lisa Wenninger (she/her) has a PhD in Counselor Education and Supervision from Antioch University Seattle. She is a National Certified Counselor and is licensed in California and Washington, with a telehealth-only social justice counseling practice working with individuals with marginalized identities who are navigating a complex and difficult world. Dr. Wenninger serves on the Board of Counselors for Social Justice to promote advocacy and allyship within the counseling profession and help nurture development of the professional identity of counselor-advocate in colleagues. Dr. Wenninger makes a point to attend the meetings of the California Board of Behavioral Sciences and in other ways stay on top of laws and regulations affecting counselors and our clients. She regularly provides continuing education courses on topics such as law and ethics of telehealth, culturally informed diagnosing, and antiracism in counseling, and consults with organizations interested in building more inclusive and welcoming cultures.
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Resonant Equity, Inc. has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 7682. Programs that do not qualify for NBCC credit are clearly identified. Resonant Equity, Inc. is solely responsible for all aspects of the programs. |
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Defensive Documentation Part 1In this section, we emphasize how documentation can be a social justice practice, especially considering current legal changes that can affect vulnerable clients. The need for ethical considerations is highlighted, including non-maleficence and tending to client intersectionality. The speaker shares personal experiences and encourages critical thinking and community support during chaotic times. The session aims to provide a framework for creating concise, sensitive notes that prioritize client confidentiality.
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Laws targeting identities -
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Defensive Documentation Part 2
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Defensive Documentation Part 3
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Defensive Documentation Post-TestHere's where you can check your knowledge from the training! A passing score of 75% is required to get the CE certificate. Retakes allowed. -
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Course Evaluation
Continuing Education Program Policies
By registering for this course, you accept and agree to these policies.
NBCC Approved Continuing Education Provider
Resonant Equity, Inc. has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 7682. Programs that do not qualify for NBCC credit are clearly identified. Resonant Equity, Inc. is solely responsible for all aspects of the programs.
Refunds and Cancellations for On-Demand Programs
Because access is given instantly, refunds are not available for on-demand programs.
Completion Requirements – Home Study Programs
Resonant Equity, Inc. is approved by NBCC as a continuing education provider of home study (on-demand) training programs for mental health providers (ACEP #7682). In order to award CE hours, participants must complete the full duration of training, including watching any videos or listening to audio content in its entirety (no fast forward or skipping ahead), and reading all provided text-based learning materials in full. Completion is also verified by passing the assessment that checks knowledge based on the training content. CE certificates cannot be issued until completion is confirmed. Wherever possible, we implement technology based tracking to support these requirements, however some course content relies on the honor system for participants to attest to completion. We hope that our training content is engaging enough that you choose to take full advantage of the learning opportunities we design.
CE Certificates
Completion of all lessons in the course including watching any videos in full, then passing a post-test for knowledge check, are required to be eligible to earn CE hours. The course evaluation must be submitted within 30 days of completion. The CE certificate will be generated once the evaluation is received and sent to your email address on file. If you are missing a CE certificate for a training that you believe you qualified for, please reach out to programs@resonantequity.org to inquire.
Accommodations
Resonant Equity, Inc. conducts all programs in alignment with the requirements of the Americans with Disabilities Act (ADA). If you would like to request accommodations in order to participate in one of our programs, please email us when you register or at least 7 days ahead of the program date to inform us of your needs so that we may develop a solution together.
Acceptance of All and Non-Discriminatory Stance
Resonant Equity, Inc. does not discriminate against any individual or group with respect to any service, program, or activity on the basis of gender identity; race or ethnicity; national origin, citizenship, or immigration status; sexual or romantic affiliation; religion; age; organizational membership, or any other basis prohibited by law. We do not require program participants to accept or adhere to any religion or religious principles.
Confidentiality of Participant Information and Recording Practices
Resonant Equity, Inc. protects personal participant information received during registration, and provides the information only to those needing access in order to produce the program. We do not share participant information with other organizations without express permission from the individual.
Anyone who has registered for any Resonant Equity, Inc. program may request their data to be removed from our database by contacting us with the request, however please note that based on our record keeping and retention requirements as a CE provider, we must maintain rosters and logs for all of our participants for at least five years, and these rosters and logs may be submitted to our licensing body, NBCC, upon their request. In addition, any complaint filed with Resonant Equity, Inc. concerning our CE programs will be shared with NBCC.
Disclosure or Use of Client Information
Identifiable client information will not be disclosed by a presenter in a Resonant Equity, Inc. program. Instead, composites of real-life scenarios or clients, and fictional case examples, are designed for case conceptualization, role playing, and educational purposes. Participants asking questions in a training are directed to protect client information.
Respect for Copyright and Intellectual Property
Resonant Equity, Inc. asks all of our presenters to respect intellectual property rights, and to affirm that materials used in any Resonant Equity training or program do not infringe on rights of others, including copyright, trademark, and license rights. Resonant Equity, Inc. affirms that it either owns the materials used with respect to a qualifying program, or is permitted by law to use such materials with respect to a program. If any inappropriate use of materials is suspected in one of our programs, please contact us using the Contact form on the website and we will promptly investigate. To support academic integrity, Resonant Equity, Inc. requires presenters to include a reference list for all sources included in their presentation. Except for noted references and citations, the program content itself is protected intellectual property of Resonant Equity, Inc. and/or the presenter, and Resonant Equity, Inc. requests that participants do not record our programs.
Complaints
Concerns or complaints from any participant or potential participant about Resonant Equity, Inc. or a continuing education program we provide may be submitted directly to Resonant Equity, Inc. using the Contact Us form on our website. Please provide a valid email address on such submission. Although we cannot guarantee a particular outcome, we will consider all complaints submitted, make any necessary decisions, and respond within 3 weeks of receipt. Formal complaints about our continuing education programs are forwarded to NBCC as part of our ACEP agreement with them.
ACEP Provider Contact Information
For purposes of inquiry into any of our programs and policies, or to request accommodations as a participant, please use the Contact form on our website at https://resonantequity.org/about/contact/. Resonant Equity, Inc. may also be reached at programs@resonantequity.org.
Counselors, counselor educators, and other mental health professionals.
