therapist-documentation

Audit therapy and behavioral health documentation platforms for clinical quality and regulatory compliance. Reviews SOAP, DAP, and BIRP note template structure, note completeness enforcement and timeliness deadlines, note locking and amendment/addendum workflows, DSM-5 diagnostic code completeness, ICD-10-CM crosswalk accuracy and annual update currency, diagnostic code validation and billing alignment, informed consent lifecycle (treatment, telehealth, release of information, minor consent) with electronic signature and expiration enforcement, treatment plan documentation (goals, objectives, interventions, review periods) with plan-note linkage, clinical supervision hour tracking for licensure (individual, group, direct observation), supervisory co-signature enforcement, and HIPAA compliance (RBAC with minimum-necessary access, encryption at rest and in transit, audit logging with 6-year retention, breach detection, PHI leak prevention in logs and errors, client record access and amen