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Everything You Need to Know:

Documentation for New Jersey Social Workers in Private Practice

Sunday, November 5, 2023

9:30-3:00, EST

Live, Interactive on Zoom

Everything You Need to Know—Documentation for New Jersey Social Workers in Private Practice, #4859, 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. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE course approval period: 3/16/2023-03/16/2025.  Social workers completing this course receive 5 Ethics continuing education credits.

ACE individual course approval meets the NJ Board of Social Work Examiners requirements for individual course approval pursuant to NJ Code 13:44G-6.4.16.

Approved Delivery Methods and Formats: 
In-person
Distance learning: Live, interactive and synchronous distance​

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:

  1. Identify and apply general documentation and record-keeping guidelines

  2. Outline key elements of the clinical medical record

  3. Recite the essential features of a compliant progress note   

  4. Discuss ethical standards and legal mandates around privacy and confidentiality relating to clients and others access to the medical 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 clinician in private practice.  The NASW Code of Ethics provides social workers with a comprehensive set of guidelines outlining professional norms, while the NJ Social Work Statutes and Regulations and federal 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/medical records.      

Agenda
Program will be 5 hours of actual time
There will be two, 10 minute breaks mid-morning and mid-afternoon

Lunch will be 30 minutes on your own

Fee

$125.00


Program

Introduction (15 minutes)

Goals
Overview of the importance of documentation, record-keeping, meeting the Standard of Care and risk management in private practice
Compliance and characteristics of a suitable case record (20 minutes: lecture)
The NASW Code of Ethics, NASW Standards, NJ Social Work Licensure Law and HIPAA on Record-keeping
Consequences of not maintaining, falsifying or destroying case records
Writing an accurate, objective and professionally written case record
Right of access and privacy and confidentiality (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
Who has legitimate rights to the case record? Exceptions

Privacy and Confidentiality; Denial of access, writing for your intended audience, and protection of client privacy and confidentiality. What to include and what to leave out. Insurance company access, minimum necessary standard

21st Century Cures Act

BREAK- 10 minutes

Disclosures with or without consent (20 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

Informed Consent (20 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
Overview of the elements of an acceptable medical record (50 minutes)
The NASW Code of Ethics, Standards for Clinical Social Work in Social Work Practice, New Jersey Social Work Licensure Regulations, and HIPAA on: documentation for covered entities, and the authorization to release mental health/substance abuse records.
Why and how to draft policies- financial, telehealth, Technology/communications/social media policy

Lunch break on own- 60 minute in person; 30 minutes virtual

what to include in the case record (85 minutes)

social work assessment, key components of an audit proof progress note
Accurately documenting client-social worker interactions the definition and attributes of psychotherapy notes

HIPAA, informed consent documents, social worker-client agreements
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

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
BREAK- 10 minutes

Amendments Storage, retention and destruction of the case record (40 minutes)
Amendments and corrections to the case record

How to appropriately amend paper and electronic records

Under what circumstances are you permitted/obligated to amend the case record 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

Q and A, final thoughts (10 minutes)

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, MSW, LCSW, the program administrator directly @ 973-879-1678 or @ LTsukroffLCSW@Hushmail.com

  • In order to assist in the ethical and timely resolution of grievances, Leslie S. Tsukroff, Inc.’s Auxiliary Social Work Consultant, Laura Taylor, MSW, LSW will be actively involved in addressing and resolving all disputes.  

  • 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 LTsukroffLCSW@Hushmail.com

  • Registration Deadlines:  BY MAIL 7 days prior to event. BY E-MAIL 1 day prior to the event. ONLINE- 90 minutes prior to event.

  • ​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 @ LTsukroffLCSW@Hushmail.com

 

Course Completion

Certificates will be e-mailed to participants within 7 days:
1.    Who atten
d the entire session
2.    Return a completed course evaluation.  
3.    Course evaluations will be e-mailed to registrants who attend the entire session, within 30 minutes of the workshop ending. 

How to Register

On-line: www.LeslieTsukroff.com

     Register and pay on-line with a credit card    

By Phone: 973-879-1678

     Register and pay with a credit card or

     Request a registration form

E-mail: LTsukroffLCSW@Hushmail.com

     Request a registration form


Presenter

Leslie S. Tsukroff, MSW, LCSW is the Founder and Executive Director of Leslie S. Tsukroff, Inc, which encompasses both her private psychotherapy practice and her consulting business, Business Management Consulting for Mental Health Practitioners. Leslie hails from a long line of entrepreneurs, following in the footsteps of her grandfathers, uncles, father and her mother.  Prior to launching her own psychotherapy practice in 1999, she worked in the trenches as a child/family preventative services worker, an on-site school mental health counselor, and as staff clinician at a community-based agency.  She gained further invaluable knowledge while developing clinical preventive programs for at-risk youth, spearheading startup programs for non-profits and working as an outpatient care manager during the rise of managed care during the 1990s.  

 

Leslie is a recognized authority in professional ethics, risk management and private practice development in New Jersey. Her passion for social work professional ethics grew from her interest in the law and her prior employment at a law firm during college. While she determined early on that a career in law was not the right fit for her, serving on the NASW-NJ Ethics Committee and later being appointed Chairperson presented the opportunity to meld her clinical, ethical and legal worlds.

 

Most recently, she had the honor and privilege of serving on a task force charged with developing a new, comprehensive, and practical document for NASW entitled, “Clinical Social Workers in Private Practice: A Reference Manual.” In addition to providing input on the entire document, Leslie lent her professional ethics and private practice expertise by authoring sections on the subjects of professional wills, retirement and closing a private practice, minor's rights, issues impacting minors whose parents are divorced/separated, business planning, subpoenas, sliding scales, client–social worker practice agreements, informed consent standards and suggested case record forms.

 

With close to 3 decades of giving back to the social work and mental health communities, Leslie has served on various Boards of Directors, written articles, offered pro-bono presentations, and provided low-cost supervision and consultation to mental health professionals throughout the tri-state area.  As a Qualified Clinical Supervisor in New Jersey, she is committed to ensuring future generations of clinical social workers have the necessary skills to practice competently and ethically. Throughout her career she has served on several professional committees/task forces focused on continuing education for social workers, private practitioner concerns, insurance and managed care issues and social work licensure rules and requirements.
 

Leslie conducts engaging training workshops focusing on traditional business practices, risk management, documentation and record-keeping, private practice development, billing, ethical and legal issues and clinical matters. She has a passion for the collaborative learning process, and drawing on her clinical/ethics–related expertise she provides customized clinical, ethical, and private practice building consultations.  

 

In addition to her mental health consulting business, she maintains an office in Somerville, New Jersey and provides remote psychotherapy to clients located in New Jersey and Pennsylvania. 

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