Defensive Documentation

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.

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.