I was a 1099 contractor during my clinical internship.

Grateful an agency had even taken a chance on me.

I had a clinical supervisor on paper. Barely any real training on documentation.

No EHR system. Just a basic Word doc template and a lot of guessing.

I thought documenting meant writing everything. Every word my client said. What they looked like in session. What happened minute by minute.

I thought more detail meant I was covered.

I was wrong. And no one ever sat me down to correct it.

The Call That Exposed the Gap

Years later, in my first year of private practice, I got a call out of nowhere from a UHC reviewer.

She wanted to know about a client's progress. Why weekly sessions were still medically necessary.

I had the notes. I just didn't have them organized in a way that let me answer with confidence.

I remember flipping back through session after session, trying to piece together a story that should have already been sitting right there on the page.

That call didn't go badly. But it was the moment I realized my documentation was a liability I hadn't noticed yet.

What I Wish Someone Had Told Me

A colleague of mine, an attorney with Yellowood Legal, said something once that stuck with me.

Your notes need to be thorough enough that no one questions your competency. Not so long that they create problems if an attorney or a board ever picks them apart.

That's the exact lesson I learned the hard way, put into one sentence.

Documentation isn't about writing more or writing less. It's about writing with clinical reasoning that someone who was never in the room can follow.

The Do's

✔ Write toward medical necessity, every session

✔ Connect each note back to the treatment plan

✔ Document high-risk situations the way you'd want them read back to you in a courtroom

✔ Build a documentation habit, not a documentation scramble

✔ Ask periodically whether your template is still serving you

The Don'ts

Don't mistake a full EHR template for a complete note. A template gives you structure. It doesn't teach you what belongs in each box.

Don't write transcript style notes. More words isn't more protection.

Don't wait for an audit, subpoena, or ROI request to find out your system doesn't hold up.

Don't assume "no one taught me" means you're behind. Almost none of us were formally taught this.

Don't keep guessing. The cost isn't just your stress. It's your client's care and your license.

Why I Built This Training

After my own audit, I built a group practice of 17 clinicians. Grad students, interns, licensed providers, all walking in with some version of the same struggles I once had.

So I built the system I never got. One that means if we're ever audited, subpoenaed, or asked for an ROI, we can hand it over with confidence instead of dread.

That system, refined over years of running a real practice with real staff, is what I teach in The Do's and Don'ts of Clinical Documentation.

📅 Wednesday, September 25 · 1:00 to 4:30 PM PT · Live on Zoom

In this live training, you'll learn how to:

✔ Document everyday sessions, high risk situations, and telehealth compliance with clarity

✔ Use AI tools without losing your clinical judgment

✔ Build a self-audit habit you actually keep

✔ Walk away with SOAP and DAP templates, a treatment plan example, and a self-audit checklist

3.5 Ethics CEUs. Nevada Board Approved.

If no one ever sat you down and taught you this either, what would change for you if someone finally did?

👉 Register here