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The Golden Thread: Using Medical Record Documentation Templates to Prove Medical Necessity

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As a provider, you use clinical decision-making to assess client needs and potential benefits of therapy. Treatment is deemed necessary rather than just desired by the client. That’s why medical necessity should be evident in high-quality clinical documentation to provide accurate information as to why treatment is medically necessary for your clients. 

What is the Golden Thread? 

The Golden Thread is a concept in healthcare related to clinical documentation and best clinical practice. It “ties together” or creates a cohesive narrative of a client’s experience in an episode of care and provides clear evidence of medical necessity. The narrative is documented in therapist documentation in the client’s record.


Using the right templates to document the Golden Thread

The Golden Thread is a critical component in providing quality care and meeting accreditation, compliance and reimbursement requirements. But how do you know if you’re using the correct documentation? That’s why we’ve compiled templates for medical record documentation notes as a resource for SonderMind providers:

These notes provide evidence of medical necessity and should be used throughout the intake and treatment process. SOAP notes are one form of medical record documentation, and the SOAP format is incorporated in the templates provided. Entering notes in the medical record is a different process than using psychotherapy notes (which are kept separately).

If you’re a SonderMind provider, copy and paste the information from the completed template into the “Note” field in your SonderMind portal with your claim submission. You can also use your own templates if they meet payor standards which are typically aligned with CMS (Centers for Medicare and Medicaid Services).

Training for high-quality documentation
As a SonderMind provider, you have access to comprehensive training on medical documentation, including how this documentation is used to protect both you and your clients during insurance audits, subpoenas, board complaints, and other legal matters. Watch the training here

If you’re not a SonderMind provider, we invite you to join a community of mental health professionals who are dedicated to providing the highest-quality care and changing people’s lives.
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You might also want to read

Initial assessment in the Golden Thread: Intake template

Road map for care in the Golden Thread: Treatment plan template

Documenting therapy sessions in the Golden Thread: Progress note template 

Documenting end of care in the Golden Thread: Discharge summary template

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**Disclaimer: This document is intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.

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