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The CCD Documentation Guide for TherapyNotes®
See how Child-Centered Documentation (CCD) translates into everyday clinical documentation within TherapyNotes® EHR. This 38-page guide includes complete examples using both standard SOAP templates and customized note templates, along with a full Dibs case example demonstrating the CCD process from intake through ongoing care.
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About This Guide
Documenting Child-Centered Play Therapy within an electronic health record can be challenging when trying to balance child-centered values with documentation and managed care requirements.
This guide demonstrates how the Child-Centered Documentation (CCD) framework can be applied within TherapyNotes® through completed clinical examples.
While a few sections discuss TherapyNotes®-specific customization features, the primary focus is on illustrating how case conceptualization, treatment planning, progress assessment, and documentation connect through the CCD process.
Included in This Guide
Practical examples of applying the Child-Centered Documentation (CCD) framework within TherapyNotes® EHR.
Getting Started with CCD in TherapyNotes®
- CCD implementation tips
- A custom CCPT intervention library to add to your TherapyNotes® checklist options
Example #1: Using CCD with Standard SOAP Templates
- Intake Session Note
- Diagnosis and Clinical Justification
- Treatment Plan
- Play Therapy Progress Note
- Caregiver Progress Note
Example #2: Using CCD with Customized Templates —Dibs Through the CCD Lens
- Intake Session Note
- Diagnosis and Clinical Justification
- Behaviors of Concern Checklist
- Case Conceptualization
- Simple Planning Sheet
- Treatment Plan
- Play Therapy Progress Notes
- Caregiver Progress Note
Additional Resources
- Sample customized TherapyNotes® play therapy progress note templates that meet managed care requirements*
- Sample customized TherapyNotes® caregiver session note templates that meet managed requirements*
- Customized client history form for TherapyNotes®
- CCD play therapy intervention list
Bonus Resources Included
Behaviors of Concern Checklist
A structured tool for identifying and tracking behaviors of concern while developing measurable symptom objectives for treatment planning and progress assessment.
Case Conceptualization Template
A child-centered framework that helps therapists understand the internal experiences and growth needs underlying a child's behaviors and symptoms.
Simple Planning Sheet
A visual planning tool that brings together diagnosis, symptom objectives, growth objectives, and treatment goals in one place.
Frequently Asked Questions
Will this guide teach me how to use TherapyNotes®?
No. This guide assumes a basic familiarity with TherapyNotes® and is not intended as a step-by-step tutorial of the platform. A few sections discuss TherapyNotes®-specific features, such as custom templates and intervention libraries, but the primary focus is on demonstrating how the CCD framework can be applied within an electronic health record.
I don't use TherapyNotes®. Will I still find this resource helpful?
Yes. Although some sections reference TherapyNotes® features, the primary focus is on the CCD process.
Clinicians who have read Dibs in Search of Self may find this resource particularly helpful, as it demonstrates how the CCD framework can be applied to the case from intake through treatment planning and progress assessment.
The sample templates and documentation language may also provide ideas for adapting CCD concepts within other EHR systems.
Clinicians who have read Dibs in Search of Self may find this resource particularly helpful, as it demonstrates how the CCD framework can be applied to the case from intake through treatment planning and progress assessment.
The sample templates and documentation language may also provide ideas for adapting CCD concepts within other EHR systems.
I have completed the CCD Self-Paced Course and/or read Play Therapy Documentation Essentials. Is this guide still helpful?
Yes. This guide focuses on implementation. It provides examples of how CCD concepts can be translated into treatment plans, progress notes, caregiver documentation, and electronic health records.
Are the CCD tools included?
Yes. The guide includes the Behaviors of Concern Checklist, Case Conceptualization Template, and Simple Planning Sheet used throughout the Dibs example.
These resources represent a portion of the CCD tools used in practice. Clinicians interested in exploring additional templates, growth objective resources, progress assessment tools, and other components of the CCD framework may also find the CCD Workflow & Desk Reference (WFDR) helpful.
These resources represent a portion of the CCD tools used in practice. Clinicians interested in exploring additional templates, growth objective resources, progress assessment tools, and other components of the CCD framework may also find the CCD Workflow & Desk Reference (WFDR) helpful.
Is this affiliated with TherapyNotes®?
No. I am not affiliated with TherapyNotes® and do not receive financial compensation from TherapyNotes®. TherapyNotes® is simply the EHR I use in practice, and the examples are provided to illustrate how the CCD framework can be applied within an electronic health record.
*Legal Disclaimer
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