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Digital Seminar

Clinical Documentation Crash Course

Best Practices and AI-Assisted Tools to Write Quick, Ethical and In-Compliance Notes

Speaker:
Andrew Huber, MA, LMFT
Duration:
4.25 Hours
Copyright:
Jul 17, 2026
Product Code:
POS150810
Media Type:
Digital Seminar - Also available: Live Webinar

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Description

Write Better Notes, Save Time and Safely Use AI-Assisted Tools … all in one Fast-Track 4 Hour Program

  • Write progress notes in 5-7 minutes without losing clinical depth
  • Create documentation that clearly demonstrates medical necessity
  • Understand legal and ethical standards
  • Use AI wisely: what’s ethical, what’s risky, and what truly helps

 

You want to stay present with clients … but the moment your last session ends, the notes start piling up.

Progress notes, treatment plans, and medical necessity documentation can quickly become overwhelming.

And with the rise of AI-assisted tools things are getting even more confusing …

…What’s allowed? What’s ethical? What’s safe? What actually helps?

That’s why we teamed up with Andrew Huber, LMFT, a seasoned clinician and co-founder of Therapy Self, a platform focused on streamlining documentation. Andrew has the tips, tools and strategies for busy clinicians who want:

  • Clear, confident, defensible documentation
  • Efficient workflows that save hours each week
  • Ethical guidance on using AI
  • Real-world examples and walk-throughs

In this 4-hour training he’ll share all he knows with you, so you can create notes that tell the clinical story, demonstrate progress, strengthen treatment planning, and support high-quality client care …

… Plus how you can use AI-assistance to help create notes faster and better than ever – all legally and ethically compliant.

If you want to feel in control of your notes, not behind on them, this course is for you.

Purchase now!

Credit

Planning Committee Disclosure - No relevant relationships

All members of the PESI, Inc. planning committee have provided disclosures of financial relationships with ineligible organizations and any relevant non-financial relationships prior to planning content for this activity. None of the committee members had relevant financial relationships with ineligible companies or other potentially biasing relationships to disclose to learners.  For speaker disclosures, please see the faculty biography.


AI Use Disclosure

A small portion of the material for this CE activity was developed with limited assistance from generative AI. All AI-generated information was reviewed for accuracy by the instructor, an independent content reviewer, or PESI staff.



* Credit Note - Self-Study CE Information Coming Soon

Continuing education credit information is coming soon for this non-interactive self-study package.

CE hours may be available for select professions, as listed in the target audience. Hours will be dependent on the actual recording time. Please check with your state licensing board or organization for specific requirements. 

There may be an additional fee for CE certificates. Please contact our Customer Service at 1-800-844-8260 for more details. 

**Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of your profession. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your professions standards.



Speaker

Andrew Huber, MA, LMFT Related seminars and products


Andrew Huber, MA, LMFT, is a licensed marriage and family therapist with over a decade of clinical and administrative experience in mental health care. He has spent nine years working in private group practice and eight years in adolescence psychiatric settings, where he developed a deep understanding of effective and defensible clinical documentation. As the clinical co-founder of Therapy Shelf, an innovative software platform designed to help therapists streamline documentation, Andrew brings a unique blend of clinical expertise, systems thinking, and technical insight. He is passionate about teaching therapists how to write clear, efficient, and ethical documentation that strengthens both clinical care and professional confidence.

 

Speaker Disclosures:
Financial: Andrew Huber has employment relationships with Sycamore Grove and Therapy Shelf. He receives a speaking honorarium from PESI, Inc. He has no relevant financial relationships.
Non-financial: Andrew Huber is a member of the California Association of Marriage and Family Therapists.

 


Additional Info

Access for Self-Study (Non-Interactive)

Access never expires for this product.


Questions?

Visit our FAQ page at www.pesi.com/faq or contact us at www.pesi.com/info


Objectives

  • Analyze the ethical, legal, and regulatory standards that guide clinical documentation and medical necessity.
  • Develop progress notes that clearly document interventions, client response, and clinical rationale.
  • Choose treatment plan goals that are measurable, client-centered, and interconnected with progress notes.
  • Differentiate between ethical and unethical use of AI in clinical documentation, including risk areas related to HIPAA, confidentiality, and PHI.

Outline

Documentation Formats

Learn how to choose the right note structure so your documentation is clear, consistent, and audit-ready

  • Purposes of progress notes
  • Different formats of documentation including SOAP, DAP, and BIRP
  • Risks, research and limitations

Progress Notes: Writing Clear, Defensible Notes

Master writing progress notes that are complete, defensible, and efficient – without wasting time or over-documenting

  • Essentials in a progress note
  • What auditors and insurers expect
  • How much detail is enough for medical necessity
  • Establishing notes level of granularity
  • Words that trigger red flags
  • Completeness checklist

Treatment Plans: Link Goals to Documentation

Create treatment plans that align with client goals, meet payer standards, and stay easy to update as needs change

  • Essentials in a treatment plan
  • Establishing plans level of granularity
  • Adjusting treatment plans

Ethical HER and AI: How to Work Smarter without Risk

Discover safe, ethical ways to use EHR systems and AI tools to speed up documentation without risking compliance or client privacy

  • Safety strategies with EHRs
  • Basics of AI notetaking capacities
  • Reviewing AI notes

Other Types of  Clinical Documentation

Understand the differences between progress notes, psychotherapy notes, scratch notes, and chart notes – so you never mix them up

  • Progress vs. psychotherapy notes – legal and clinical differences
  • Scratch notes & chart notes – What belongs where – and what never should
  • Risk of mixing note types – how mistakes lead to audits or lawsuits

Quick Tips

Get practical strategies to write faster, stay organized, and build a workflow that saves hours every week

  • Speeding up notes
  • Using templates
  • Batch documentation
  • Staying accountable for documentation

Target Audience

  • Counselors
  • Social Workers
  • Marriage and Family Therapists
  • Psychologists
  • Registered Psychotherapists
  • Physicians
  • Psychiatrists
  • Mental Health Nurses
  • Addiction Counselors
  • Other Mental Health Professionals

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