Clinical Language in Documentation

Refine your clinical documentation skills with a focus on progress notes and treatment plans. This course builds confidence in your ability to produce concise, medically relevant, and outcome-driven documentation that supports the effective integration of evidence-based treatments. Participants will utilize the “golden thread” to ensure consistency across assessments, diagnoses, and interventions, while clearly demonstrating medical necessity. You’ll also gain practical strategies to avoid both over-disclosure and under representation of clinical care. This course is ideal for ALL practitioners, from interns to provisional licenses, and independent licenses.
Format

Live Webinar

Beginner, Intermediate, Advanced
Date

Aug. 19, 2026
10am Central

Author

Theresa O'Keefe

LCSW, LMSW, MS
Credit Type

NBCC

Duration

2 Hours

Price

$50

About the course

Refine your clinical documentation skills with a focus on progress notes and treatment plans. This course builds confidence in your ability to produce concise, medically relevant, and outcome-driven documentation that supports the effective integration of evidence-based treatments. Participants will utilize the “golden thread” to ensure consistency across assessments, diagnoses, and interventions, while clearly demonstrating medical necessity. You’ll also gain practical strategies to avoid both over-disclosure and under representation of clinical care. This course is ideal for ALL practitioners, from interns to provisional licenses, and independent licenses.

Objectives

  • Review principles of medical language and the "golden thread"
  • Learn case conceptualization for documentation
  • Develop practical skills to apply clinical language into documentation
As the training arm of Heart and Solutions, You Need a Training is owned and operated by Heart and Solutions, LLC. All aspects of continuing education trainings offered by You Need a Training, are the sole responsibility of Heart and Solutions.
Heart And Solutions has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 7376. Programs that do not qualify for NBCC credit are clearly identified. Heart and Solutions is solely responsible for all aspects of the programs.

Course Lessons

Theresa O'Keefe

LCSW, LMSW, MS
Theresa is a Licensed Clinical Social Worker and owner of Secure Base Therapy, a private practice in Missoula. Theresa works primarily with clients with trauma and attachment issues, integrating EMDR, EFT and expressive arts into treatment. She has taken a leading role in sharing education on attachment theory in her community and works from a perspective that prioritizes emotions, relationships, and building secure working models with her clients.

More from Theresa

Cancelation Policy:

All refund requests must be made in writing a minimum of 14 days prior to the date of the training. Every effort will be made to achieve resolution, including, but not limited to: full/partial refunds, course substitutions, future credit towards other courses/training.

Please contact Dr. Colleen Grote, Vice President of Therapy Heart and Solutions for additional information.

Returned Payment Policy:

All returned checks or invalid disputes will incur a $25 charge to cover fees and administrative time
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