Welcome everybody to another episode of The Testing Psychologist podcast. This is Dr. Jeremy Sharp. Today, I’m excited about my guest, Dr. Maelisa Hall. Maelisa and I were originally introduced through Kelly Higdon, who will also be on the podcast here in a few weeks, but Kelly is a private practice consultant here based out of California and she consults with a lot of really cool folks.
And when I got in touch with her, Kelly said, you have got to talk with Maelisa. Maelisa has this awesome business going on and you two would be a great fit. I reached out to Maelisa and it was a great connection.
And so [00:01:00] I invited her to come here on the podcast to talk with us about all sorts of things but we’ll focus probably on her two main businesses, which are QA Prep, which helps therapists get all the paperwork in order and documentation. And then she also has a private practice, but you’ll hear plenty about that as we go along.
So Maelisa, just briefly, welcome to the podcast.
Dr. Maelisa: Thanks for having me. I’m excited to be here.
Dr. Sharp: Absolutely. Let me read your official bio here and then we will just dive into it, okay?
Dr. Maelisa: Cool.
Dr. Sharp: Great. Dr. Maelisa Hall is a licensed psychologist and serial entrepreneur living in Southern California. She loves talking about productivity, time management, business, and online marketing. Maelisa pays the bills with her two psychology-related passion projects, QA Prep, and Hall coaching group.
Maelisa, can you tell us a little bit more about each of those [00:02:00] businesses and what you’re up to these days?
Dr. Maelisa: Yeah. So definitely keeping busy with both of those. QA Prep is an online business that I’ve had for almost three years now. With QA Prep, I help other therapists with their documentation. So I offer training and webinars, CE classes, all kinds of things, free blogs, and everything related to how to make your documentation more simple, easier, and more meaningful. That’s my big focus with QA Prep is how can you enjoy your documentation a little bit so that it’s not this boring task or this dark cloud that’s always hanging over your head.
Dr. Sharp: Wow. Enjoy your documentation, is that a paradox or what?
Dr. Maelisa: It’s possible or at the very least, not hate it.
[00:03:00] Dr. Sharp: I’ll take that. No, I trust you. If you say you can help enjoy your paperwork, I totally believe you and look forward to talking about all that.Dr. Maelisa: Like with anything, when you can find some meaning in it, then you can figure out how to motivate yourself to get it done and you can start to enjoy it a little bit more or see the value in it at the very least. And then with my private practice, I do counseling online and I also have an office and I offer assessments. I do a career assessment and ADHD testing with adults. So two really specific testing areas.
Dr. Sharp: Absolutely. I would love to talk with you about both of those and how you set those up in your practice. Maybe we [00:04:00] can save that for a little bit later though, because something you said just about QA Prep and the paperwork jumped out to me already.
You said that you have to find some meaning in it to make it enjoyable or a passion for you. Could you talk a little bit about how you came to start QA Prep and what led you to that? Paperwork, people wouldn’t think paperwork, that’s my passion. So I’m really curious how it became yours.
Dr. Maelisa: Absolutely. I started out from the very beginning, my first practicum doing testing. And so everything that I was doing with the field of psychology was very paperwork-heavy and detail-heavy. It’s important that you’re accurate when you’re doing testing and that you’re making sure to cross all your T’s and dot your I’s, et cetera, and report writing and all of that.
I found that [00:05:00] I enjoyed testing a lot. And so I think that helped me with the paperwork part of it, too, because I saw how valuable the testing reports were to people and how much meaning they could provide. And then I took that with me as I moved more into providing psychotherapy at the end of my internships and then after I graduated from graduate school.
I worked in an agency where, LA County is infamous for their documentation practices related to Medi-Cal, which is everywhere else, it’s called Medicaid, but here in California, we call it Medi-Cal. The paperwork is just crazy. It’s mountains and mountains of paperwork that you have to do in order to provide psychotherapy to people.
It wasn’t a big problem for me because I do [00:06:00] tend to be a good writer and I was able to use that as a time to reflect. So that’s one of the suggestions I offer people is when I was writing my notes, I was making sure to take the time to think about the sessions. It was almost like I was processing the sessions myself as I was writing the notes.
Not that I’m this perfect person who did that every single time, sometimes I had to get a note done, but for me, it offered me that respite from what was a fairly stressful job. I also was thrown into this position where I had to do a lot of intake assessments and the intake assessments were really long. They were typically two to three hours long and pretty intense, pretty severe clients and we had this huge waiting list.
And so I had to learn very [00:07:00] early on how to manage that and how to manage my time or that would have gotten completely out of hand because there’s so much paperwork with an intake assessment and so much documentation that you have to do right away or you’ll forget a lot of really valuable information.
So I think between those two things, I learned to manage the paperwork well, and it never became a huge issue for me. We all get behind our paperwork every once in a while, and that did happen to me, but for the most part, I was able to manage it fairly well, and I was able to catch up very quickly when I did fall behind.
So fast forward, a few years, and did other things. And then I found a job, actually working at that same agency, I went back to them, doing quality improvement. And so that was training therapists at the agency on how to do the documentation. And then actually going in and [00:08:00] auditing charts, which wasn’t my favorite part of the job.
Even with that, it was auditing charts and then providing the program director’s reports and information on what pieces were missing, what they needed help with, how to improve, and then creating training that was specialized to each program to help them overcome whatever struggles they had, each program would tend to have different weaknesses.
As I started doing that, I got all this feedback that people were like, oh, this training is so helpful. We never got anything like this in graduate school. I kept hearing the same thing over and over again. And then I started helping people who were in private practice because I had all this information about insurance and general documentation and realized that nobody in private practice has anything like this.
There is very little training in this area. So I decided to start QA Prep and offer that [00:09:00] training. And that’s what I’ve been doing ever since.
Dr. Sharp: Good for you. You’re so right. I remember back when I was getting started and probably for years after that, the process of finding guidelines for how to do all of the paperwork, especially with insurance was really hard. I feel like it’s gotten maybe a little easier over the past two years, but maybe that’s due in part to some of your materials that are out there and helping guide people.
Dr. Maelisa: Thanks. Honestly, I don’t have a lot of competition. In regards to insurance, there’s one or two other people who offer some information, but even without insurance, if you’re a private practitioner, there are very few guidelines.
One of the things that I do in my training is I start off with the general ethical guidelines related to documentation. I give the actual description from APA and [00:10:00] AAMFT and these different national associations. They all just say you have to document, but they don’t say how, so we get very little guidance.
Dr. Sharp: That’s a great question. So how did you fill in the gaps there in the guidelines? How did you know what to put in your policies?
Dr. Maelisa: That’s where the auditing has come in handy. Being someone who has gone into other people’s practices, and read other people’s notes and their client files, you start to see a lot of the same things come up over and over again. It becomes very obvious what people are missing.
So with documentation in general, one of the things I talk about is having a story and that’s what your client’s file is, is a story, whether you’re in private practice [00:11:00] doing testing or doing therapy or whatever. It’s the story that you have of your treatment with them.
When you’re looking at a file and you’ve never seen this client, you don’t know anything about them at all. And so I would go in and do this objective audit. It becomes very obvious where the holes in that story are.
For example, a really common thing that people miss, that people don’t think about is making little notes on things like rescheduling or when the next appointment is, or like a vacation. I might be reading a file and then there are three weeks that are completely missing. I’m like, well, what happened here? There’s three weeks that are just gone and that could be anything, it could be somebody lost their notes. It could be they never wrote the notes or it could be the client was on vacation for three weeks so they didn’t come back. If you don’t write that down, then nobody who’s looking through the file knows what happened.
Dr. Sharp: Oh, that’s [00:12:00] interesting. Sorry to interrupt you, even right off the bat, that’s something that is relatively new to me. Typically, in the past when I was doing more therapy, if clients went on vacation or took a little break for whatever reason, that’s just what happened. I don’t know that I necessarily documented that clearly.
Dr. Maelisa: It doesn’t have to be a big deal. It could just be like at the end of one session note, maybe in the plan section, you just write client will be on vacation for the next three weeks and return on XYZ date for the next session. But even adding a little thing like that closes that gap. So that’s a basic example of things that you learn as you spend time reading other people’s notes.
I think another thing is one of the exercises I have people do in workshops and in training, especially early on when [00:13:00] I was learning how to do training was that I have people write notes together as a group. So we give an example client, everyone writes a note as if they did a psychotherapy session with them. And then we compare notes.
In the beginning, it can be really scary. Everybody’s like, oh my gosh, I got to read my note aloud. Everybody’s going to think my note is horrible but you find that everyone tends to write very similar things and we are covering the same thing, maybe saying it a little bit differently.
Of course, there are exceptions and there are times when people might leave out something that was important or add things that aren’t important, but in general, you find those guidelines, which you would find from maybe doing consultation with people, things like that. That’s one of the things I offer too, is just ideas for people of how do you find what that [00:14:00] norm is for your profession?
Dr. Sharp: Something I run into a lot and I think I hear on Facebook groups and message boards and things like that is how much do you include in your notes, especially when you’re dealing with the insurance? Can you speak to that at all?
Dr. Maelisa: Yeah. Most of my answers with documentation are usually it depends, which everybody hates, but that’s because it really does depend on the situation. So with insurance, it’s not about length. So it’s never about how long your note is or how much you write in a note, regardless of whether it’s insurance or private pay, whatever. What matters is the information that’s in there.
So with insurance, things that you want to make sure that you include are what progress the client is making because insurance companies don’t want to pay for a service that isn’t working and they won’t eventually. [00:15:00] If they saw that you were doing therapy for 12 weeks and you said that the client is still so impaired, they need so much help and you didn’t talk at all about any progress that was made, they’re going to say, okay, well, that was great. It was a trial and it didn’t help at all. We’re done.
So it’s balancing identifying that progress with also identifying that need because on the other side of the coin is the fact that this person has made some progress but they still need this service and why. So it’s making sure to identify those two things. I recommend people put one sentence that has both of those things in there in every note. In that way, it reminds you to address those two key points every time you’re writing a note that relates to insurance.
Now there are more specific things depending on who you’re billing to, for [00:16:00] example, Medicare and Medicaid or Medi-Cal do tend to be more stringent and you might want to put in some extra things like making sure that you identify specific interventions and making sure that you have enough information to justify the amount of time you bill is the biggest thing.
But generally, for most private insurance companies, it’s not that dramatic, but you want to identify those two key points; what’s the progress being made and what is the ongoing need? And then talk about what you did. You simply just talk about what you did in your session.
Dr. Sharp: Sure. I know that a lot of folks are using EHR systems these days. There’s SimplePractice, TheraNest, and TherapyNotes and there are any number of solutions out there. Have you checked any of those out and from a documentation standpoint, do you have any thoughts on which of those might have advantages over another or [00:17:00] are they all pretty good or what?
Dr. Maelisa: Yes, what a timely question. I’m interviewing quite a few of them and putting together what I hope will be an epic blog post highlighting how you write notes within the different EHRs. I do hope to have that out in two weeks. I’m not sure when this interview will be airing but hopefully, it’ll come out around the same time. So you can check that out on my blog.
Dr. Sharp: Oh, that’d be great. And while I’m thinking about it, what’s the address of your blog or website?
Dr. Maelisa: qaprep.com.
Dr. Sharp: Okay. Perfect.
Dr. Maelisa: Pretty easy to remember. Part of the reason I’m reaching out to them is because I know this is a big issue. What you bring up is what people are thinking of. As far as notes go, I would say that a lot of the EHRs are pretty similar and you’re writing your note.
The [00:18:00] big difference is whether or not you can customize your note template. For some people, that’s more important than it is for others. For me, honestly, it’s not a huge deal because I’m pretty comfortable writing freeform or I can use a structured template. One of the things I am not a huge fan of is pre-populated check boxes.
I know a lot of people want to have notes where like, oh, okay, I just check off interventions that I do, or I just check off ways in which the client presented. And that I think can be helpful but only after you have written your own notes for a while because what a lot of people do is they get all these check boxes and then they’re making things up. They’re checking them off because they have to [00:19:00] whereas if you write your notes, let’s say using a template like DAP or SOAP or some of these common templates, which I also talk about on my blog, and I have a free crash course people can sign up for, and I talk about all that stuff more in-depth, and do give some samples too.
When you’re looking at that, you then get used to writing, and you notice what are the phrases that you use because the type of therapy you do might be very different from the type of therapy I do, or the type of clients you see might be very different. If I give people a list of checkboxes, it’s not going to be individualized to their clients or to what they provide and they’re going to start overlooking a lot of the things because it doesn’t apply to them.
So if you write your own notes for maybe six months and then go through and do a review of your notes and pick out the things you find [00:20:00] yourself writing over and over again and then create your own checkboxes, your own template, that’s totally different because that’s going to be a really meaningful, really powerful tool for you to use that will save you time and still provide that meaning and still be very individualized to what you do.
Dr. Sharp: That’s a great tip. It’s funny, as you were talking, I was glancing over at my EHR to see if that’s doable. I use TherapyNotes, I’ve talked about that on the podcast before and it does have the capability to write in custom interventions. You can tailor it to your specific approach. That’s a great idea.
Dr. Maelisa: And that’s one of the biggest things. Most of the EHRs offer a free trial. I tell people, just sign up for two of them and see what you like because you might like one that I don’t like. There are so [00:21:00] many things within an EHR. Personally, I use CounSol. I would actually say their notes are not my favorite. They have two different forms of notes, and so I use the freeform one. Their more formalized note process is not customizable, and it has a lot of those check boxes that I don’t like, so it’s not my favorite.
However, everything else with the EHR is exactly what I wanted. It has everything I wanted except that. So for me, it’s ironic, one of my big focus with QA Prep is notes, but in my own private practice, that’s the least favorite part of my EHR.
But everything else, like with the intake paperwork was huge and it offers online sessions within the system for me, that was important to have one place to go for everything for myself and for the clients. So you just have to try them [00:22:00] out and see what works best for your practice.
Dr. Sharp: Sure. That’s great. Well, let me switch gears just a little bit and ask you about documentation for testing and assessment in particular. Do you have thoughts on that? Any special considerations for those of us who are doing a lot of testing and evaluation; what to consider? What to keep in mind? That kind of thing.
Dr. Maelisa: Yeah, I think one of the big things starting from the beginning is informed consent and making sure that your consent forms are customized for testing. I do have a paperwork packet for sale and I have a testing add-on form, I call it because I do think that reviewing with clients how psychological testing or any kind of testing is different from therapy and what it adds to the process and how that might change the relationship you have with them and who is going to receive the results. Those are all [00:23:00] really important things to review at the beginning.
I think in a similar way to therapy, we can’t guarantee the outcome. I think this is something that a lot of people actually miss reviewing with clients at the beginning of psychotherapy as well and it’s maybe a little bit easier to do with testing is even if someone calls me for ADHD assessments, for example, I typically can tell whether or not they’re going to have a diagnosis based on that initial conversation with them because, with that, it tends to be fairly specific.
I do testing with adults and so they’ve typically done a lot of their own research and put a lot of thought into the process before coming to me. So it’s usually just a confirmation of what they already thought, but it’s important for me to tell people, I can’t guarantee you’re going to have this diagnosis. I can’t guarantee what’s going to happen.
The point of testing is to gather [00:24:00] information. And so we’re going to gather lots of information. We’re going to look at everything we can and regardless of what results may come, I will be able to give you a lot of information about yourself and hopefully, you’ll be able to get a lot of insight.
Regardless, we’ll be able to go through some recommendations for what you’re struggling with because typically people aren’t coming to testing because everything’s going perfectly fine in their life. They think something is wrong either with themselves or with maybe their child. And so they want help and they want some guidance as to how to deal with whatever’s going on. And that’s what the testing can offer. And that we can provide regardless of what the results are, right?
Dr. Sharp: Sure. Do you include all of that in that paperwork packet; making it pretty explicit, everything that you just said about the uncertainty of results and whatnot?
Dr. Maelisa: It’s not quite as detailed in there on the paperwork packet. I don’t remember the exact language I [00:25:00] have right now, but it’s more about the difference between psychotherapy and the fact that you can’t guarantee results and the potential benefits and drawbacks.
I think it’s important to review with people too, that they may or may not be happy with the results and that results aren’t always easy to digest, and that’s hopefully where, as clinicians, we do a good job of providing that feedback to people and in a compassionate way, but sometimes it’s hard information to hear.
Sometimes people are really happy to get a diagnosis or find out certain information because they’re like, thank God I’m not, that term lazy, crazy, or stupid. This gives me an explanation for what’s been going on. Other times people are upset and they say, well, what does this mean? Does this limit me? Does this mean I can’t do this? Does this mean I have to change my plans? [00:26:00] So it’s important to make sure that people understand it’s not always this happy-go-lucky thing in the beginning.
It also makes me think about one big thing that I talk about with informed consent, and this applies to testing or psychotherapy, is that it’s a conversation, it’s not a form that you have people fill out. It’s a process. None of our ethical guidelines say that informed consent is a document. It’s something that you review with your clients and then our forms are legal and paper or electronic representation of the fact that we did review that with them. So it’s important that we have the conversation.
So while I do have clients fill out forms and obviously sign the forms, it’s a talk that I’m having with them and I’m making sure that they have looked through it and that they understand all those things.
Dr. Sharp: That’s such a good point. That’s interesting. I’ve never [00:27:00] heard anyone phrase it that way but when you say that, that totally makes sense. We have people sign the paperwork that says that they are consenting to treatment but how we present that is, there’s a lot of variation and responsibility on us to go through it appropriately and have that conversation like you said.
Dr. Maelisa: Yeah, I find that actually some people get a little bit annoyed with doing intake paperwork because it can be time-consuming and you feel like, oh, we have to go through all these forms and I’m not going through my forms in depth with people or going through everything line by line. I wouldn’t recommend doing that, but I would definitely recommend making sure you highlight those key points with people and have that conversation, I’ve never had anyone be annoyed that we talked about that part of it.
Dr. Sharp: Yeah, that’s interesting. The last episode that I did was [00:28:00] all about the vulnerability of coming in for testing and going through that process. I talk about how I restructured my initial interviews to be two hours long, in large part so that I could spend the time that I needed to at the beginning, to talk them through the process and orient them to testing and I think talk through a lot of these things that you’re mentioning.
Dr. Maelisa: Yeah. I heard that episode and I thought it was a great point because you want to make sure, and sometimes people have more questions than you think they’re going to have and you want to make sure people have the space to get all of that answered.
Dr. Sharp: Absolutely. So what are some other things that folks who focus on testing might want to keep in mind from a documentation standpoint?
Dr. Maelisa: I think the other big thing, what comes up with testing a lot more than with psychotherapy is sharing of documentation. And so making sure you have that identified ahead [00:29:00] of time.
All of the ADHD assessments I’ve done up to this point, actually, and I just started doing assessments in my private practice in the last two months but all of them have been referrals from other therapists or, actually, there were two people who came in, but they all were in their own psychotherapy. So I knew right off the bat that they were going to be sharing this report with somebody else and that it would be beneficial for them to do that with their ongoing therapist.
So that’s something you want to think about; is it going to a school? Is it something that they’ll want to hang on to and keep for a long time? And so you want to consider that when you’re writing your report, obviously, but also when you talk about authorizations to release information and making sure that you do have authorizations.
Sometimes that can get a little bit tricky because we’ll do a lot of treatment planning type stuff and [00:30:00] working with other practitioners and I think that’s a great thing. I think that we as therapists get a little too scared sometimes to share information and it can be really helpful for our clients, but just making sure you have your legal documents in a row as far as that goes.
And then also considering storage of records. I think you talked about this in one of your podcasts about, like if you store your records electronically, are you scanning the protocols into your EHR or are you just keeping the paper copies locked up in a separate file? Those are things you want to consider that I think are a little bit different with testing because it’s not something that you are directly entering into the EHR. You are going to have all these separate forms that you’re going to have to figure out what to do with.
Dr. Sharp: Yeah. Do you have thoughts on what you would do with all that?
Dr. Maelisa: I like scanning everything in. I think that’s what you do too. Is that correct?
Dr. Sharp: We do.
Dr. Maelisa: Just [00:31:00] because it’s easier to have everything in one place and the point to me in having an EHR so I don’t have to worry about having things locked up in separate cabinets and carry them around for the next seven years. If that’s not something you want to do, it’s perfectly acceptable to keep the protocols in a separate file.
I do always make sure that the report is definitely uploaded into the EHR and I give clients copies of the report. I want to make sure that is a little bit more open access for them to have.
Dr. Sharp: Got you. That makes sense. Going back to the consent to release information piece, I think that’s really important. What I run into a lot is parents will come in, we work with kids primarily so I have a lot of kids that are under 15, which is the age of consent for treatment here in Colorado. [00:32:00] They’ll always have questions about; do we release it to the school. Do we send it to the physician?
In many cases, they’ll say we want to release part of it to the school and the full report to the physician and some of it to the therapist and things like that. It can get tricky with the actual consent form. Speaking very frankly, I don’t think my consent form probably specifies all of those different ways to release it like it should, does that make sense?
Dr. Maelisa: Yeah. On the consent form that I have, I leave it blank for the ongoing form and then I’ll write in or type in what it is that I’m releasing to each person. So that’s what I would recommend is you personalize it based on what you’re releasing because parents and [00:33:00] individuals very well may want different information released to different places.
Dr. Sharp: That makes sense. Got you. Can you speak to anything with regard to the other end of the spectrum with teenagers and those who fall above the age of consent but lower than 18, or the age when most kids move out of the house?
I find that gets tricky sometimes with documentation in that, this is a lengthy explanation, so bear with me here, where parents will come in, seek the evaluation, the adolescent will sign the consent form and consent to treatment but then inevitably something will come up during the course of the evaluation. They’ll mention, let’s say, drug use or alcohol use or something that has some bearing on the diagnostic picture but then they say, don’t tell my parents. And so I am curious, from a [00:34:00] documentation standpoint and testing-wise, how you might handle something like that. I’m going to totally put you on the spot here.
Dr. Maelisa: I know, and that’s a good one. Well, thankfully, I can cop out a little bit and say that I don’t work with teens right now but this actually is something that is a little bit different in every state. So I would encourage people to make sure you know the guidelines for your state regarding adolescence and whether or not they can choose not to have their certain information released to their parents because in some circumstances, you can say, well, this report is going to the kid and it’s up to them to determine if they want to share it. Obviously, that gets tricky because it’s typically not the teen that’s paying for it, and all that stuff.
I think the big thing is knowing what your state guidelines are as far as that rule, and then making sure that you’re very clear with the parents and with the adolescent [00:35:00] upfront about those things. I used to work with adolescents a lot more and I would give very specific examples like that and tell people ahead of time.
Typically, let’s say an adolescent said that they were smoking marijuana. That’s not, for me, going to be one of the big deal things that I’m going to say, okay, well, remember when we had that conversation in the beginning about something was really harmful to you, I might have to tell your parents. That’s not usually going to be the thing that I’m going to be like, oh, I have to bring Mom in now and have a whole conversation with her.
However, with testing, it can be really important to the information, because if they say that they got high this morning and you’re testing them right now, that’s going to impact your results. So with testing, I think it actually can be a lot more important. And so I think it’s important that you talk with [00:36:00] the adolescent ahead of time about that stuff and make sure that they know that they need to avoid doing those things the day before testing and the day of testing and that kind of stuff.
Dr. Sharp: Of course. That makes sense. Do you happen to know, you mentioned checking your state guidelines, I know in some regards there are lists of state-by-state guidelines for certain practices, do you know if there’s anything like that for mental health or psychologists, anyone aggregate website that people could check?
Dr. Maelisa: Not for releasing records. I know there is one. There is a law group who put one together for online counseling guidelines and that’s really helpful. So they may be someone to check out and see if they have anything that could be similar to releasing records because typically states take their direction from HIPAA, [00:37:00] but then some states are more stringent than HIPAA and some states are less stringent than HIPAA. So that’s where you have to determine, okay, what’s the state, what’s HIPAA and how do they play together?
Dr. Sharp: Sure. That makes sense. Okay. I’ll do a little research and maybe try to throw that information in the show notes if I can find it.
Dr. Maelisa: Usually that’s one of those things where people who have recently graduated know more about it than us because they’ve been sitting for state licensing exams. I think most of us on our state licensing exam, that’s one of the questions or one of the topics you have to study. So that’s another area you could check out.
Dr. Sharp: That sounds good. This has been great. We’ve talked for quite a while and I still feel like we’re barely scratching the surface with paperwork and documentation. [00:38:00] Two things, before we totally wrap up, are there other things at all that you feel like would be important for folks to know, especially doing testing and thinking about documentation or insurance before we wrap up.
Dr. Maelisa: That’s a good point. I think with insurance, it’s really important in that first note that you write to make sure that you’re justifying why the testing is medically necessary and that’s going to be different for every insurance company. One of the things I recommend people do is simply google whatever insurance company you contract with and then medical necessity guidelines. So like, Magellan’s psychological testing medical necessity.
If you google that, you should be able to find whatever their guidelines are and that way you’ll have a clear understanding of when they think it is necessary and when it’s not, so when it’ll be approved, and then make sure that you specifically speak to those points in your notes, [00:39:00] which may never be reviewed. It may not be a big deal, but just in case, that way you have it and you don’t have to worry about it. That’s one of the biggest things.
And then to document what you’re doing. I think with testing, sometimes too, we think, we’re not doing psychotherapy and we’re going to write up this big report and so we may want to write a little bit less in our notes and at least, document what behavioral observations you saw. Anything of note or of importance that wasn’t specifically a result on the test and then document what tests you gave for each session
Dr. Sharp: Sure. That makes sense. Again, depending on your EHR, I know that TherapyNotes is really good about that. That’s one of the reasons that I chose them is they are pretty specific with forcing you to document all of the testing that you do and separate them out; how much time you spend on each one, [00:40:00] that kind of thing.
Dr. Maelisa: Yeah. I think it’s a little bit easier if you’re testing to create a template for yourself. You have a fairly standard battery that you give and it makes it a little bit easier for note writing, but make sure that you do include that personalized part because the way each person presents during a testing session is totally different.
Dr. Sharp: Absolutely. This is great. Maelisa, you mentioned a lot of resources over the course of the podcast that I would think would be pretty interesting to folks with paperwork and documentation. Can you just say again, how people could get in touch with you if they wanted to find some of these resources?
Dr. Maelisa: Sure. They can go to qaprep.com. I have a pretty extensive blog. I may have to preen that a little bit over the next year or so to organize things over the past few years, but there’s a lot of stuff in there you can [00:41:00] read. I also have a free crash course, so you can just click on get the free crash course or something like that on the website.
In there, I go through all the different forms you need in your private practice, how to do treatment planning, how to write notes, and give a bunch of different types of templates that you can use, including my templates that I created called meaningful templates. Especially if you struggle with what to write, that’s why I created those. They’re discussion prompts for you about what to include in your session notes. So that’s always a free resource for people too.
Dr. Sharp: That’s fantastic. I can vouch for your website and your blog. I’ve been on there. Maybe you say you need to preen it but there is a ton of good information on there about things that, well, with notes and paperwork in general, it’s easy to just let [00:42:00] that stuff slide and get into habits that may or may not be appropriate, so the information you have on there gets into the nuts and bolts of how to do documentation and it’s awesome. So definitely recommend that people check that out.
Dr. Maelisa: Awesome. Thanks.
Dr. Sharp: Oh yeah, absolutely. Well, thank you so much for your time. This went by really quickly and who knows, maybe down the road we’ll have part two of the paperwork and documentation but in the meantime, it was really great to talk with you and I appreciate you coming on The Testing Psychologist podcast.
Dr. Maelisa: I appreciate you having me and thanks to everybody for listening.
Dr. Sharp: Yeah. Take care of Maelisa.
Dr. Maelisa: All right.
Dr. Sharp: Hey, thanks everybody for listening to that episode with Dr. Maelisa Hall. I hope you learned something from my conversation with her. I know that I sure did. After we had that podcast, I went and checked out all sorts of resources. I mean it when I say that her website [00:43:00] is comprehensive and her blog has some cool stuff on it that helps us address some of those mundane things that are easy to overlook but not so easy to get out of trouble if you happen to get audited or something. So definitely check out her website. That information is in the show notes.
Thanks as always for listening. It is great to see the community continue to grow and see the downloads go up and just know that more folks are jumping on board with learning about testing and growing and starting testing services in their practices. So if you enjoy the podcast, do me a big favor; you can share it on social media, you can share it on your blog, you can write a review, you can rate the podcast in iTunes, any number of things, and share it with your colleagues. All of those are helpful.
If you do want to join our community and have some conversation with other folks who are doing testing in their practices; you [00:44:00] can check that out at Facebook, The Testing Psychologist community. If you want more information or want to read some articles or check out more information, you can go to the website, which is thetestingpsychologist.com.
I hope to catch you next week. I am going to be talking with Kelly Higdon, one of the premier private practice consultants. I can just say as a little teaser that my conversation with Kelly had me walking away rethinking how I might structure my practice. She has some powerful things to say for us. So hope to see you next week. Take care in the meantime. Bye bye.