Using Medical Record Documentation Templates

1
min read

Entering notes in the medical record is a different process than using psychotherapy notes (which are kept separately). As a resource for SonderMind providers, we’ve compiled templates for medical record documentation notes below.

SonderMind providers should use these templates throughout the intake and treatment process. These brief notes provide clear evidence of medical necessity, which is required for payors. SOAP notes are one form of medical record documentation, and the SOAP format is incorporated in the templates below.

After using these templates, copy and paste the information into the “Note” field in your SonderMind portal with claim submission.

For more information 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 this training.

**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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