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03/25/19 Dr. Hall CE Program
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Record Keeping & Documentation: Best Practices to Keep You Safe, in Compliance, and With Peace of Mind Experience

When: Monday, March 25, 2019
9:00 AM - 1:00 PM
Where: The California Endowment - The Center for Healthy Communities
1000 N. Alameda St.
Los Angeles, California  90012
United States
Contact: LACPA Office

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 Program time changed as of 1/10/19


Monday, March 25, 2019   9:00 a.m. - 1:00 p.m.

4.0 CE Credits

Record Keeping & Documentation: Best Practices to Keep You Safe,
in Compliance, and With Peace of Mind


Presenter: Maelisa Hall, Psy.D.



This workshop may be counted toward the ethics requirement mandated every two years for license renewal.




Held at The California Endowment 

The Center for Healthy Communities

1000 N. Alameda Ave.

Los Angeles, CA 90012


 Program fee includes continental breakfast and parking.


This event has very limited seating, register early to avoid disappointment.

This program is fully subscribed.  


This presentation will be recorded and all in attendance will need to sign a recording release
form as they enter.  

Please note that the camera will be trained only on the speaker during the presentation, but there is a possibility that audience members' voice, image, or likeness may be recorded on audio or videotape. The Q and A part of the event will not be recorded.



Case notes are commonly written in private and hidden away, making the experience confusing and anxiety-provoking for even seasoned psychologists. Due to the necessary limits to confidentiality, psychologists rarely read one another’s notes as a matter of practice. Instead, notes tend to be available only at the request of the client or during situations commonly viewed as negative, such as during a board investigation or court proceedings.


This advanced workshop will provide direction based on ethical principles, as well as a supportive format for discussing and practicing note writing in real time among colleagues. Most mental health professionals find the exercise of writing notes together to be cathartic and affirming, as well as informative. Attendees will be encouraged to evaluate their client population and modality when considering what best applies to their practice, and to share with one another throughout the workshop so as to establish a standard of care based upon ethical and legal principles.


Maelisa Hall, Psy.D., is a psychologist, entrepreneur and co-host of the My Biz Bestie podcast. Through her online continuing education business, QA Prep, she specializes in teaching therapists how to connect with their paperwork so it’s more simple and more meaningful. Dr. Hall enjoys creating trainings that are interactive and engaging. Her love of online marketing and collaboration mean that she is always networking and sharing resources within the mental health community, even while living on a sailboat in Southern California.


Course Goals and Educational Objectives:

1- Create an individualized case note template that applies to psychotherapy practice.   

2- Describe the common similarities in note writing among various practitioners.

3- Evaluate which laws and ethical principles to use in supporting individualized documentation practices.

4- Assess the acceptable level of risk related to technology in documentation.


Course Outline:

1.     Opening Introductions & Schedule for the Session (10 minutes)

1.     LACPA representative intro

2.     Share your practice specialty

3.     A note about participating in a supportive environment

2.     Introduction to Meaningful Notes (30 minutes)

1.     The impact of notes on client care

2.     How to make note writing meaningful

1.     Preparation

2.     Reflection

3.     Visualization

3.     Common templates in mental health

1.     DAP

2.     GIRP

3.     SOAP

4.     Templates for various scenarios

1.     Reflective-based notes

2.     Relationship-based notes

3.     Results-based notes

3.     Mock session and participant exercise (45 minutes)

1.     Review of a mock session via video

2.     Exercise: Write a therapy note

3.     Discussion of the experience

1.     Sharing notes (2-4 participants)

2.     Common themes among notes

3.     Differences among the practitioners

4.     Ethical Dilemmas in Writing Notes (60 minutes)

1.     Common mistakes to avoid

1.     Writing too much (review example)

2.     Writing too little (review example)

3.     Over focusing on insurance requirements

4.     Ignoring insurance requirements

5.     Falling behind in notes

2.     Introduction to review tools

1.     Integrating basic quality improvement techniques

2.     Potential questions to use

3.     Introduction to workshop template

3.     Presentation of two scenarios

4.     Discussion of scenarios: using ethical codes to guide your decision-making

5.     Five minute break (5 minutes)

6.     Technology, Notes and Ethics (60 minutes)

1.     Ethical considerations in technology

2.     How to create a risk assessment

3.     How to identify the best option for notes

1.     Using a computer

2.     Cloud-based systems

4.     Organizational tools

1.     Keep a schedule

2.     Use a template

3.     Use technology

5.     Scenario review and discussion

7.     Final Thoughts (30 minutes)

1.     Discussion: sharing of experiences in real life practices


Program, presenter, date, and location are all subject to change.

Cancellation Policy: To receive a refund, a written request must be received the Monday before the scheduled date of the program. Refunds will be processed within 30 days. A $35 processing fee is deducted from all refunds. Should it become necessary to cancel a course, those who have registered will be notified in writing, and the full course fee will be refunded.

It is important to note that APA continuing education rules require that LACPA only give credit to those who attend the entire workshop.  An evaluation of the workshop must be completed. Those who arrive more than 15 minutes after the scheduled start time or leave before the workshop is complete will not receive CE credit. Partial credit may not be given. 


The Los Angeles County Psychological Association (LACPA) is approved by the American Psychological Association to sponsor continuing education for psychologists. LACPA maintains responsibility for this program and its content.


This course may be taken to satisfy both the California Board of Psychology (BOP) and Behavioral Sciences (BBS) continuing education requirements. 


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