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Nov 30, 2020

Noteworthy Documentation

An interview with Dr. Ben Caldwell, LMFT about some basic documentation information as well as updates relevant to the 21st Century Cures Act. Curt and Katie talk with Ben about what to consider when writing your notes including what to include and what should not be included. We look at who can see your progress notes as well as other considerations related to records requests and confidentiality.       

It’s time to reimagine therapy and what it means to be a therapist. To support you as a whole person and a therapist, your hosts, Curt Widhalm and Katie Vernoy talk about how to approach the role of therapist in the modern age.

Interview with Dr. Ben Caldwell, LMFT

Dr. Benjamin Caldwell, PsyD is a California Licensed Marriage and Family Therapist (#42723) and the Education and Director for SimplePractice Learning. He currently serves as adjunct faculty for California State University Northridge in Los Angeles. He has taught at the graduate level for more than 15 years, primarily in Law and Ethics, and has written and trained extensively on ethical applications in mental health care. In addition to serving a three-year term on the AAMFT Ethics Committee, Dr. Caldwell served as the Chair of the Legislative and Advocacy Committee for AAMFT-California for 10 years. He served as Editor for the Users Guide to the 2015 AAMFT Code of Ethics and is the author for several books, including Saving Psychotherapy and Basics of California Law for LMFTS, LPCCs, and LCSWs.

In this episode we talk about:

  • Documentation as our favorite thing ever
  • Excitement about Ben breaking the record on number of interviews on this podcast
  • What needs to go into your documentation
  • Accurate, adequate, and timely
  • Standard of care
  • How much information to put into your notes
  • Who is the audience for your documentation
  • Who might request records
  • The importance documentation in continuity of care
  • Where to put client quotes
  • The difference between progress and process or psychotherapy notes
  • What can be subpoenaed (including psychotherapy notes)
  • How much information you include based on what is advisable to protect self
  • The benefit of doing documentation for yourself as well as for treatment efficacy
  • The 21st Century Cures Act – Open Notes (deadline now extended through April 2021)
  • Optional certification process that requires clients to have access to all the information in their chart without charging them)
  • Most mental health providers have no changes required from this change
  • Most private practice EHRs are not on these systems
  • Hospitals may have this requirement, but individual practitioners are not responsible for the mechanism to provide documentation to clients
  • How to make sure you’re ready for clients to see your documentation
  • The communication is going on for people who are required to comply with this open notes mandate, including how to access information and who to contact with questions
  • In most states, clients have a fundamental right to request their records
  • Confidentiality and access to records for family members, especially parents of minor children
  • Conversations to have at the beginning of treatment in these situations regarding what will be included in the chart (and what will not be put into the chart)
  • What not to include in your chart (specifically written reports from child abuse reports)
  • A debate of who owns the record – who can see them is different from who owns them

Our Generous Sponsors:

GreenOak Accounting

If you love dreaming about growing your practice, but you feel a disconnect between where you are now and where you want to be, check out GreenOak Accounting. You went to school to become a therapist, not an accountant! Your time is much better spent doing what you love–and not crunching numbers. That’s where GreenOak Accounting comes in! They specialize in working with private practices just like yours, so you can reclaim precious hours each week! They can help with all your accounting needs like bookkeeping, budgeting, forecasting, payroll and even assist with implementing Profit First. If you are interested in freeing up your schedule for more clients, or just getting back time for yourself, go to to schedule a free, no obligation consultation today. You can also check out our podcast, Therapy for Your Money, hosted by GreenOak Accounting owner Julie Herres.

CPH & Associates

CPH & Associates is an insurance company that specializes in professional liability insurance for mental health professionals. We currently insure over 100,000 mental health professionals throughout the United States. We can insure you throughout your professional career starting with your student practicum, through your post masters internship, and on to practicing with your professional license.

With up-to-date legal resources and exceptional customer service, CPH protects your career against a grievance from a regulatory board, claim, or lawsuit. Because our business is specialized, we are able to focus on your liability needs in a way that bigger companies are not. We are able to serve a large client base while maintaining a small-office approach. With options to add General Liability, Cyber Liability, and coverage for your LLC or corporation, a policy with CPH is tailored specifically to meet your liability needs. Policy holders are encouraged to take advantage of our Attorney Avoiding Liability Helpline, providing two free hours of attorney consultation per year for situations with a client that could result in a claim or lawsuit. With our online application and renewal process, real-time online policy change capabilities and knowledgeable customer service, we continue to keep our customers’ needs a priority! Get a quote and apply online to receive proof of coverage within minutes at


Resources mentioned:

We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!

The 21st Century Cures Act

Open Notes Org article related to the Cures Act

Simple Practice Learning

Course: HIPAA in the age of COVID-19


Relevant Episodes:

Episodes with Dr. Ben Caldwell –

The Fight to Save Psychotherapy

Defining the Therapy Movement

COVID-19 Legal and Ethical Updates

Dr. Maelisa Hall: Make Your Paperwork Meaningful

Nicol Stolar-Peterson: CYA for Court

Barbara Griswold: Busting Insurance Myths


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Who we are:

Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making "dad jokes" and usually has a half-empty cup of coffee somewhere nearby. Learn more at:

Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also Past President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt's youthful energy, so that she can take over the world. Learn more at:

A Quick Note:

Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.

Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.


Stay in Touch:

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Voice Over by DW McCann

Music by Crystal Grooms Mangano