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68 North Bridge Street
Somerville, New Jersey 08876
TEL:  973.879.1678  • LsTsukroff@aol.com
 

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Everything You Need to Know

Documentation in Private Practice

Join New Jersey’s premier ethics consultant, Leslie S. Tsukroff, MSW, LCSW for an informative and interactive workshop in which participants will leave being able to:

  • Identify and apply general documentation and record-keeping guidelines

  • Outline key elements of the clinical and financial case record

  • Recite the essential features of a quality progress note

  • Discuss ethical standards and legal mandates around privacy and confidentiality relating to clients and others access to the case record and the social worker's obligations to release/protect the client record
     


Course Description

Developing and maintaining quality case records and implementing prudent documentation practices is essential for the social worker in private practice.  The NASW Code of Ethics provides all social workers with a comprehensive set of guidelines outlining professional norms, while the NJ Social Work Statutes and Regulations and Federal HIPAA Laws prescribe legal directives around professional conduct for social workers practicing in New Jersey.  The primary goal of all three documents is to protect the client by establishing the “Standard of Care” for the professional practice of social work, but none specifically address the unique experience of the private practitioner.   In this workshop, the presenter will compare and contrast how these and other relevant documents address the characteristics of a case record that complies with current ethical and legal standards for social workers in private practice. Attendees of this workshop receive an in-depth view of the clinical and financial elements of the case record; progress notes; records retention and destruction; confidentiality and privacy and the release of the case record; and clients and others access to the case record.

Target Audience
This workshop is designed for the intermediate level private practitioner who wishes to gain a better understanding of how to fulfill their ethical and legal obligations to create, maintain and protect their clients' clinical and financial case records.

Agenda
Program will be 5 hours of actual time
There will be 2 15 minute breaks mid-morning and mid-afternoon

Lunch will be 60 minutes on your own

Program
Introduction (15 minutes)
Overview of the importance of documentation, record-keeping, meeting the Standard of Care and risk management in private practice
 

Amendments and corrections to the case record (15 Minutes)
How to appropriately amend paper and electronic records
Under what circumstances are you permitted/obligated to amend the case record

Compliance (10 minutes: lecture)
The NASW Code of Ethics, NJ Social Work Licensure Law and HIPAA on Record-keeping
Consequences of not maintaining, falsifying or destroying case records

Client’s right to review/receive a copy of the case record (10 minutes)
Who has legitimate rights to the case record? Denial of access, writing for your intended audience, and protection of client privacy and confidentiality. What to include and what to leave out

Characteristics of a suitable case record (10 minutes)
Writing an accurate, objective and professionally written case record

Informed Consent (10 minutes)
What is Informed Consent and how does it apply to clinical record-keeping?
The NASW Code of Ethics, Standards for Clinical Social Work in Social Work Practice, New Jersey Social Work Licensure Regulations, and HIPAA on meeting informed consent standards
Developing and implementing policies, procedures and forms

BREAK- 15 minutes

Overview of the elements of an acceptable case record (45 minutes)
The NASW Code of Ethics, Standards for Clinical Social Work in Social Work Practice, New Jersey Social Work Licensure Regulations, and HIPAA on: what to include in the case record, the definition and attributes of psychotherapy notes, documentation for covered entities, and the authorization to release mental health/substance abuse records.
Why and how to draft a Technology policy, a Contract for treatment and Termination documents

Progress notes (35 minutes)
How to write an audit proof progress note
Accurately documenting client-social worker interactions

Lunch break on own- 1 hour

Documentation of financial matters (25 minutes)

Informed Consent and how does it applies to financial record-keeping
The NASW Code of Ethics, Standards for Clinical Social Work in Social Work Practice, New Jersey Social Work Licensure Regulations, and HIPAA on meeting informed consent standards
Development and implementing financial policies, procedures and forms

Storage, retention and destruction of the case record (35 minutes)
The NASW Code of Ethics, HIPAA and The New Jersey Social Work Statutes and Regulations on the protection of paper and electronic records
Maintaining privacy and confidentiality: from authorized and unauthorized individuals; during storage with active and inactive clients; during destruction
Methods and documentation of ethically and legally disposing electronic and paper case records
Review of keeping a records destruction log
What you need to know about retaining and destroying case records- state laws, NASW, Managed care contracts and Medicare and Medicaid

Privacy and confidentiality of the case record (40 Minutes)
Definitions of privacy and confidentiality
The NASW Code of Ethics, New Jersey Social Work Statutes and Regulations, New Jersey State Laws, HIPAA  
Informed consent --The who, what, where, when, why and how to P and C
Exceptions to P and C
How to determine and handle: valid requests for the case record; Social worker and/or client denial of access to the case record; Insurance company requests for records/confidential information
When is a summary acceptable?  
The HIPAA Privacy Rule and accepting and/or disseminating a client’s PHI to/from family members/those who care for the client

BREAK- 15 minutes

Psychotherapy Notes (25 minutes)
What is a psychotherapy note and how does it differ from a Progress Note?
Why and how HIPAA treats psychotherapy notes differently
When can a psychotherapy note be accessed by others?
Review of the Minimum necessary standard
Recommendations of how to respond to a request for psychotherapy notes

Exceptions to confidentiality (25 minutes)
What to do when the NASW Code of Ethics, The New Jersey Social Work Statutes and Regulations and HIPAA give differing guidelines/mandates around a client’s right to privacy
Circumstances under which social workers are permitted/obligated to disclose confidential information without a client’s prior consent
Review of duty to protect, the importance of the use of professional judgment, how and when to apply the principle of preemption, minimum necessary standard and submitting a treatment summary


Presenter
Leslie S. Tsukroff, MSW, LCSW began her entrepreneurial career in 1999 when she opened her first private practice location in Somerset County, New Jersey. Since earning her MSW in Clinical Social Work in 1993 from New York University, she gained expert knowledge through an extensive career.

In addition to owning a profitable and successful private practice, in 2000, Ms. Tsukroff developed Business Management Consulting for Mental Health Practitioners, a corporation aimed at assisting behavioral health clinicians achieve their business goals.

Ms. Tsukroff perfected her consulting business out of knowledge she gained through creating and managing her own small business, working as an Outpatient Care Manager for one of New Jersey’s largest Managed Care Companies, and from spearheading start-up programs for former employers.

Ms. Tsukroff’s commitment to core social work values is evidenced by her volunteerism to various professional mental health associations. She is the former Chairperson for The New Jersey Chapter of The National Association of Social Workers Committee on Ethical Review and throughout her career she has served on several additional committees focused on continuing education for social workers, private practitioner concerns, insurance and managed care issues and social work licensure rules and requirements.

Ms. Tsukroff has dedicated over 26 years focused on giving back to the social work community through serving on various Boards of Directors, writing articles, offering pro-bono presentations, and providing low-cost supervision and consultation to social workers throughout the tristate area.  

In February of 2018, Ms. Tsukroff accepted an invitation to join a task force charged with revising NASW’s Clinical Social Workers in Private Practice:  A Reference Guide.

Ms. Tsukroff has a passion for teaching and drawing on her clinical/ethics –related experience and expertise. She conducts engaging training workshops focusing on traditional business practices, risk management techniques, documentation and record-keeping, private practice development, billing, ethical and legal issues and clinical matters.

Deadlines, Cancellation/Refund Policies, Complaints, ADA Needs, Questions/Concerns

  • If participants have any questions or concerns or are dissatisfied with any part of the registration process, facilities, non-receipt of certificates,  the presenter or the presentation, or any other complaints, they should contact Leslie S. Tsukroff, the program administrator directly @ 973-879-1678 or @ LsTsukroff@aol.com.

  • If the results of the grievance process are unsatisfactory, New Jersey social workers have the option to contact the approving entity, with an option to appeal to their licensing board.

  • All complaints will be responded to within 7 days from the receipt of the complaint.

  • Full refunds will be given to registrants up until 1 week (7 days) prior to the event.  

  • Requests for refunds must be made in writing and mailed to Leslie S. Tsukroff, Inc., Business Management Consulting for Mental Health Practitioners, 68 North Bridge Street, Somerville, NJ 08876 or via e-mail to LsTsukroff@aol.com.

  • Mail and E-mail registration deadline is 3 days prior to the event (Event date TBD).

  • Leslie S. Tsukroff, Inc. would be happy to accommodate your ADA Needs.  Please call (973-879-1678) to discuss at least 2 weeks prior to event.

  • If you have any questions, please call Leslie S. Tsukroff, MSW, LCSW @ 973-879-1678 or e-mail her @ LsTsukroff@aol.com


Continuing Education Credit Information

Everything You Need to Know: Documentation in Private Practice, course # 2208, is approved by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program to be offered by Leslie S. Tsukroff, Inc. as an individual course. Individual courses, not providers, are approved at the course level. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. ACE course approval period: from 01/17/2019 to 01/17/2021. Social workers completing this course receive 5 Ethics continuing education credits.


Course Completion
For those who registered on-line, by phone or via mail, certificates will be handed to social workers who attend the entire session and complete a course evaluation.

For those who register on-site, certificates will be emailed/mailed within 7 days to those social workers who attend the entire session and complete a course evaluation.