Defensive Documentation: The Laws & Ethics of Advocating for & Protecting Our Clients through Clinical Notes – THURSDAY JANUARY 8

Logistics & Scheduling

Preferred date or timeframe:
Proposed length: 2 hours
Requested fee:

Curriculum & Content Plan

Content/curriculum: The entire curriculum is focused on law & ethics

Online class experiential components: slides (PowerPoint, Google Slides), chat, poll or survey

Learner experience level: Novice/Beginning Learners: No advance knowledge required

NBCC Content Area: Counselor Professional Identity and Practice Issues

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:

• Describe the purpose, ownership, and legal considerations of clinical notes for mental health treatment.
• Name at least 3 recent or pending state or federal law changes that may impact clients based on identity.
• Define the concept of medical necessity in the context of clinical notes for mental health counseling and psychotherapy.
• 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.

References:

Presenters

Presenter Name: Lisa Wenninger, PhD, MBA, LPCC, LMHC, NCC, BC-TMH

Pronouns: she/her
Email: lisa@myriadsites.com
For this training, this presenter’s background and expertise qualifies them for this NBCC Presenter Category: Category 1: Graduate degree in mental health field, and qualified by education, training, or authorship for this specific subject
Presenter CV/Resume : https://resonantequity.org/wp-content/uploads/formidable/3/WenningerLisa-CV-Nov2024-2-2.pdf

Education:

• Doctorate: CES Antioch University 2024

Relevant experience/training related to topic :

Doctorate degree in Counselor Education and Supervision. Five years as an active participant in California BBS Board and Committee meetings on regulations.

Professional licenses (including state), and/or specific certifications that are related to this topic.:

CA LPCC #14315
WA LMHC #61478356

Presenter Bio (to be included on promotional materials):

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.

Does presenter have special needs or require any accommodations?: none
Permission to Record I give my permission to record my presentation for use by Resonant Equity in creating an on-demand version of my training content.

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Respect for Intellectual Property – All presenters attested that: The content to be presented does not infringe upon or violate intellectual property or privacy rights of any other party, including copyright, trademark, and license rights, The presenters attest that they either own the materials to be presented, and/or are permitted by law to use the materials in the proposed program.