Live Online CE Series · September, October, November 2026 · Hearten House
Clinical documentation as clinical and ethical practice
documentation is an intervention
4 CE Hours Including 2 Ethics Hours · Two Sessions, Taught Together · Live and Interactive
It’s Sunday night and you have six notes open.
You’ve been looking at the same one for twenty minutes. You know what happened in that session. You could tell a colleague about it in forty seconds and they’d understand exactly what you were working on. But the box in front of you is asking for something else, and you’re not sure what, so you write something that sounds clinical, means very little, and gets you to the next one.
Then a request for records comes in. Or a denial. Or a client asks what you’ve been writing about them. You then find out what your notes were actually for.
Somewhere there’s a treatment plan you wrote months ago and haven’t opened since. You sit down with that client on Thursday and think I don’t know where we’re going next. These are two sides of the same problem, though nobody has ever taught you that.
You’re not bad at this. Most of us were handed a template and a deadline and never told what a note is for, who reads it, or what it’s doing for the person it’s about. So documentation became the thing you do after the work instead of as a part of it, and you’ve been paying for that every Sunday since.
You were taught to see documentation as a clerical nightmare to be avoided until it becomes an actual threat. But it’s neither. It’s an intervention, and you’re already performing it, whether or not anyone ever showed you how.
“Documentation isn’t clerical work. It’s a clinical intervention, and it’s one of the places where clinical care and systems care meet. Whether we like it or not, the way we write determines what happens next for the person in front of us.”
documentation is an intervention
Most of us hear the word documentation and think “progress note.” It’s so much more than that, and that’s usually why it feels impossible.
When clinicians say they don’t know what to write, or don’t know where to go next with a client, the thing that’s missing is almost never a better note template. It’s an accurate assessment and a treatment plan that’s actually current. A note is the last link in a chain, and if the earlier links aren’t there, no amount of staring at the empty box will produce a good note.
Instead, we start where the chain starts, with a sentence a client says out loud in their intake, and we follow it all the way to discharge.
This training consists of two live sessions, taught together. The first teaches you about what documentation is for, what belongs in a legal record and what doesn’t, what happens to records once they exist, and how to recognize and document the moment a client’s needs are bigger than what you can offer. The second teaches about the “chain” itself, and the note. You’ll write during the second one.
What runs through both sessions is the same thread: documentation is the place where good clinical work either becomes visible or disappears.
It’s how a reviewer decides whether your client keeps care. It’s what a covering clinician reads at 6pm on a Friday. It’s what a subpoena gets answered with. And it’s what tells you, on Thursday, what you and this person are actually working on.
These aren’t four different skills. They’re one skill, and you can learn it.
Session OneWhat documentation is for, and what belongs in the record
We’ll start with the relationship, because that’s the part that isn’t working. Then the ethical and legal ground: what belongs in a clinical record and what belongs somewhere else, how records are kept and protected whether they’re on paper or on a screen, what a client has the right to read, and how to recognize and document the moment someone needs more than outpatient care can give them.
Session TwoThe golden thread, from a client’s own words to discharge
One thread, followed the whole way: the sentence a client says at intake, the assessment, the treatment plan objective, the progress note, the group note, the discharge summary. How to say what you observed without saying what you concluded. How to write functional impairment so it holds up. How to document experiential and group work without putting things in a chart that don’t belong there. You’ll write, and nobody’s work gets read aloud.
The two sessions work together: Both will change how you work.
this series is for you if:
- You’d like help not hating all of this.
- You want documentation that creates a through line, a thread, so that it tells you what to do next session instead of just recording what already happened.
- You’ve had a claim denied or a session downgraded and you weren’t sure what in your note caused it.
- You supervise someone, and you’re being asked to teach documentation you were never formally taught yourself.
- You’re new to outpatient documentation, or someone on your team is.
- You’re in a group practice or on your own, and nobody has ever told you what you’re supposed to do with physical records.
- You do experiential, somatic, or group work, and your sessions look strange written down.
- You want to be efficient and effective, and you’ve noticed that the advice you get is usually one or the other.
A note about scope: this series teaches documentation standards and clinical reasoning for outpatient behavioral health. It’s designed for people with clinical training and a caseload, or for people preparing to have one. It isn’t legal advice, and it isn’t specific to any one electronic health record.
Schedule
Pick the pair of dates that work for you. The content is the same in all three.
- September
- Monday the 21st and Tuesday the 22nd · 5:30 to 7:30pm Mountain 7:30pm Eastern · 4:30pm Pacific
- October
- Wednesday the 21st and Thursday the 22nd · 10:00am to 12:00pm Mountain 12:00pm Eastern · 9:00am Pacific
- November
- Saturday the 7th · 11:00am to 1:00pm and 2:00 to 4:00pm Mountain Both sessions in one day
How it runs
Live on Zoom, cameras encouraged and not required. You’ll be asked to write during the second session, privately, and nobody reads out loud unless they want to.
Handouts go out at the end rather than the beginning. That’s deliberate. We’d rather you were thinking than reading ahead.
These sessions aren’t recorded for later viewing, and there’s no on-demand option. Live and interactive is the only format that carries the CE hours without a cap, so if you want the hours, you’ll want to be there.
what you’ll leave with:
- A working definition of what documentation is for that survives contact with a bad week
- A clear line between what belongs in a clinical record and what belongs somewhere else, including the experiential work that’s hardest to write
- Practical standards for keeping and protecting records, physical and electronic, whether you’re in an agency or on your own
- A way to recognize and document when a client needs more than you can offer
- The golden thread, traced end to end, so that your treatment plan tells you what to do next instead of sitting in a folder
- A progress note structure you can use on Monday, and the reasoning underneath it so you can adapt it when your setting changes
- 4 CE hours, of which 2 are ethics
Utah LCSW, CSW, SSW, CMHC, LMFT and associates: these hours qualify.
continuing education
4 CE hours for the pair, of which 2.0 are ethics. 2 CE hours for a single session.
Utah LCSW, CSW, SSW, CMHC, LMFT and associate licensees: these hours qualify under Utah Administrative Code R156-60e-402.1. Hearten House is a licensed mental health agency providing clinical mental health services, which is one of the four categories the rule recognizes. The 2 ethics hours count toward the six hours of professional ethics, law, or ethics of technology required each renewal cycle.
For other states: NBCC-approved CE is accepted by most U.S. state licensing boards. We can’t verify eligibility for every license type, so your board is the best source to confirm.
Live, interactive, synchronous format. Certificates are issued after each session and include everything your board needs, including the ethics hours stated separately.
Hearten House has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 7754. Programs that do not qualify for NBCC credit are clearly identified. Hearten House is solely responsible for all aspects of the programs.
Learning objectives
participants who complete this series will be able to:
- Describe how clinical documentation functions as a clinical intervention and as advocacy for a client’s continued access to care.
- Apply the ethical and legal standards governing what belongs in the clinical record, how records are retained and protected across physical and electronic formats, and how to recognize and document when a client’s needs exceed the clinician’s scope.
- Trace the golden thread from a client’s own words at intake through assessment, treatment plan, progress note, and discharge summary, and compose a progress note that connects to a treatment plan objective.
- Apply the ethical standards for accuracy and specificity in the clinical record, distinguishing observation from inference, documenting functional impairment to support medical necessity, and writing group documentation that is specific to one client.
registration
Cost shouldn’t be the reason you’re not in the room.
If cost is a barrier, reach out before you talk yourself out of it. Email training@heartenhouse.com or call or text 801-410-0760 and we’ll have a transparent conversation.
Meet the trainer
Aimee Hadfield, LCSW, CP, PAT
Aimee is the founder of Hearten House, an experiential outpatient mental health treatment center in Salt Lake City, and one of only three board-certified psychodramatists in Utah. She holds licensure in Utah, New Mexico, and Montana, and was voted Best Psychotherapist/Counselor and Best Experiential Therapist in Best of Utah: Body and Mind, three years running.
She built the documentation training her own graduate students receive, which runs eight hours in their first week of internship, before they have written a single note. It’s more documentation training than most clinicians get across an entire internship, licensure, and career, and that gap is why this series exists.
Frequently Asked Questions
Do I have to take both sessions?
No, but you’ll get more out of taking both. They’re built as a pair: the first is what documentation is for and what the standards are, the second is how to do it. One session is $60 and carries 2 CE hours. Both are $95 and carry 4 CE hours, including 2 ethics hours.
Are these hours accepted for my Utah license?
Yes. Utah Administrative Code R156-60e-402.1 recognizes CE conducted or sponsored by a mental health agency that provides clinical mental health services, and Hearten House is one. Live, interactive courses have no hour cap under that rule. The 2 ethics hours apply toward the six required each cycle.
What about my license in another state?
Hearten House is an NBCC Approved Continuing Education Provider, ACEP No. 7754, and NBCC-approved CE is accepted by most U.S. licensing boards. We can’t confirm eligibility for every license type in every state, so check with your board.
Is it recorded? Can I watch later?
No. These sessions are live only, and there’s no on-demand version. Live and interactive is the format that carries CE hours without a cap, and it’s also the only way the second session works, because you’ll be writing.
What if I register and then can’t make my date?
Tell us and we’ll move you to another month at no charge. All three pairs cover the same material.
Do I need to be licensed?
No. Associates, pre-licensed clinicians, and graduate students in a clinical program are all welcome, and several of the questions this series answers are ones you’re better off having answered early.
I work in a group practice, or by myself. Is this written for agencies?
It isn’t, and that’s deliberate. Most record-keeping guidance is written for agencies, and if you’re in a small practice you’ve probably noticed that almost none of it is addressed to you. The session on records is built with you in mind.
I supervise people. Will this help me teach documentation?
It will give you standards and language you can hand to someone. A course specifically on supervising and teaching documentation is coming, and if that’s what you want, say so when you register so we know.
What’s your refund policy?
Who do I contact with questions?
Email training@heartenhouse.com or call or text 801-410-0760. We’d rather you ask than wonder.