June 25, 2025 • 29 mins
Dr. Tiana Kelly, DSocSci, MA, LPC, NCC joins me to dive into the realities of HIPAA and insurance documentation in private practice—focusing on practical tips over legal jargon. She explores common mistakes like late notes and miscoding, and shares strategies for clearer, more confident documentation. From balancing detailed vs. skeletal notes to creating templates and trusting your clinical judgment, she offers grounded advice for staying audit-ready and protecting your practice. She also touches on why AI-generated notes might not be the quick fix they seem.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:06):
(Transcribed by TurboScribe.ai. Go Unlimited to remove this message.) Hi, welcome to the Abundant Practice Podcast.
I'm Allison from Abundance Practice Building.
I have a nearly diagnosable obsession with helping
therapists build sustainable, joy-filled private practices, just
like I've done for tens of thousands of
therapists across the world.
I'm excited to help you too.
If you want to fill your practice with
ideal clients, we have loads of free resources
(00:29):
and paid support.
Go to abundancepracticebuilding.com slash links.
All right, on to the show.
Some of y'all aren't sending HIPAA-compliant
email, and it's a problem.
Even if you're paying for a business Google
Workspace account and have a signed BAA, your
emails still aren't 100% compliant.
That's where Powerbox comes in.
(00:50):
You can connect Powerbox to your Google Workspace
or Microsoft 365 email one time, and you're
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No one has to sign into portals, it
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email.
Behind the scenes, Powerbox software checks the security
settings of the recipient and ensures that the
email is sent properly, so you're not violating
HIPAA in the ways you may accidentally be
(01:10):
now.
I know, HIPAA isn't sexy, but we don't
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We check the boxes we need to check,
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Check out my friends at powerbox.com, that's
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(01:31):
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Use code abundant.
I've talked about therapy notes on here for
years.
I could talk about the features and the
benefits in my sleep, but there are a
couple of things I want you to know
about therapy notes that doesn't typically make it
into an ad script.
First is that they actually care if you
like their platform.
(01:52):
They don't only make themselves available on the
phone to troubleshoot so you don't pull your
hair out when you get stuck.
They also take member suggestions and implement those
that there's client demand for, like therapy search,
an included listing service that helps clients find
you, internal and external secure messaging, clinical outcome
measures to keep an eye on how your
clients are progressing, a super smooth super bill
(02:13):
process, real-time eligibility to check on your
client's insurance.
In my conversations with the employees there at
all levels, they all really believe in their
product and they want you to love it
too.
Second, they are proudly independently owned.
Why should you care about that?
Because as soon as venture capital becomes involved,
the focus shifts from making customers happy to
(02:34):
making investors happy.
Prices go way up, innovation plateaus, making more
money with as little output as possible becomes
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With over 100,000 therapists using their platform,
they've been able to stay incredibly successful and
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You can try two months free at therapynotes
(02:54):
.com with the coupon code ABUNDANT.
Welcome back to the Abundant Practice Podcast.
I'm your host, Alison Puryear.
I'm here with Tiana Kelly, and we are
going to be talking about notes one-on
-one.
Your notes are really important.
We know they're important.
None of us are super on fire, excited
about them.
You're probably going to want to check out
(03:16):
privatepracticebydesign.com after this conversation so that you
can get some more of what Tiana's talking
about.
Thanks for being here, Tiana.
Of course.
Yes.
Thanks for having me.
I'm super excited to dive into this conversation.
You said, it's not the most glamorous or
we're not going to have the most fun
time doing our notes, but talking about it
and making sure that we're all practicing within
(03:38):
best practice recommendations is, I think, super important
for our field, even when we don't like
to admit it.
Yeah, absolutely.
I think right now I have heard from
a lot of students who take insurance that
there's across the country in the US a
rash of clawbacks that have been happening, and
that's often due to documentation.
(03:59):
We really want to make sure that documentation
is as buttoned up as it can be,
even though none of us are like, gosh,
I wish I could do more of that.
What would you say are the basics of
what we absolutely need to have in every
single note?
Oh, that's a really good question.
(04:21):
Obviously, every EHR is going to set us
up a little bit differently for what gets
included in the note, but I think by
and large, the trends are we want to
have some data on our observations.
So you think about kind of that mental
status exam data.
I think that across the board is consistent
(04:41):
for EHRs, for how we were trained as
therapists.
What are we observing from the client in
terms of some of that mental status?
I also think our payers, specifically if you're
an insurance-based practice, they want to see
like what are the interventions we're using and
how are those interventions connected to like the
(05:02):
goal work.
They want to see evidence that the goals
are being worked on within the notes.
What's the plan?
What's the plan between sessions?
What's the plan for, you know, if you
have a tentative agenda for your next session,
how are you going to follow up about
some of the information that was maybe talked
about at the last session?
So that's kind of like the meat of,
I think, the important pieces that need to
(05:24):
be within notes, within our documentation.
Of course, there's like the logistics, making sure
that we're coding sessions correctly and capturing like
accurate times within the sessions.
So yeah, I would say that in a
nutshell, a really quick nutshell, that those would
be some of the most important pieces to
make sure we're focusing on.
And I think about like medical necessity, how
(05:47):
do those things prove medical necessity?
Yes.
Yeah, this is a big thing that I
am working on within our practice to like
strengthen our documentation around how we're trying to
prove or give evidence to some of that
medical necessity, making sure that we're finding ways
to justify what diagnoses we're providing, you know,
making sure that we're, sometimes it's going back
(06:08):
and pulling out that DSM and looking at
what criteria is the client giving me that
matches a specific diagnosis?
And then, you know, use that DSM as
your tool to write up that presenting problem,
to justify, yep, this is the diagnosis that
I'm providing or to justify, yep, these are
the goals that need to be worked on.
So yeah, I like that you bring that
(06:28):
point up because it is, it's a huge
sticking point when it comes to insurance.
And I think it does, if we do
it correctly, help to really guide our work,
our diagnosis and our treatment.
Yeah, when I was coming up as a
social worker, I went from doing like really
arduously long notes that were basically like a
rehashing of the entire session.
(06:49):
And one type of place, that's how we
were kind of trained to do our notes,
to working at a sexual assault center and
child advocacy center where our notes were likely
going to court in many circumstances.
So they became very skeletal.
And like, as long as I checked the
boxes, we didn't, we were a nonprofit, so
we didn't have to contend with insurance.
But like, to check enough boxes, while maintaining
(07:11):
enough privacy for the client, it was like
this really intricate balance of being skeletal, but
also meeting the needs of what documentation is
supposed to provide.
Where do you fall on like the skeletal
notes versus rehashing of the session?
Excellent question.
I love that you're bringing this up because
(07:31):
I, it sounds like we have very similar
backgrounds in terms of, you know, work and
where we've gotten started.
And I have, my initial training, my internship
was at a domestic violence, sexual violence agency.
So we were very skeletal.
And then I moved into partial hospitalization, and
that was give me every single detail of
(07:52):
every client every single day.
So it is a really strong skill set
you have to develop in order to get
a little bit of both, right?
Keep the detail in there when it's relevant
and important, but also cut out the fluff
when you really just don't need it, or
when it might be a detriment to the
client, to the client's safety, to the client's
(08:13):
care.
I, whenever I'm working with clinicians, you know,
in consultation about their documentation, that is the
first question that I ask them if I
don't already know that about them is, you
know, give me a sense of where you
got started in your practice, in your counseling
practice, because it does help me to understand
when I'm in there looking at their files,
and if they have really scant documentation versus
(08:36):
really, really wordy, giving me every single detail,
a lot of times I can kind of
trace that back to what their work experiences
have been thus far, you know, those ones
that it's, there's barely any detail in there.
They have had some kind of work experience,
like in some like victim services agency, which
helps me then to know like, okay, this
(08:57):
is where this is coming from.
It's not just because you don't want to
do documentation, like we can kind of cut
those judgments out.
If we just sit down and have a
conversation around like, what have your work experiences
been?
What has your training been like?
And then how now that we're in private
practice, and our payers have their own requirements,
how do we find a balance between the
two, you know, to honor like where you
(09:17):
think it's appropriate to keep the details out,
but also make sure that we're providing enough
detail that we can, for instance, justify the
treatment that's happening.
Absolutely.
And I'm curious, because we're, so we're talking
about these different workplaces, some are beholden to
insurance companies, some are not.
(09:38):
I think about this, the way some private
pay clinicians approach their notes is kind of
like, I don't really need to do this.
Like I'm not going to get audited by
an insurance company and have to pay money
back.
What is the difference in documentation from an
ethics perspective for private pay clinicians versus clinicians
(09:59):
who take insurance?
So primarily when, when I'm consulting, I'm consulting
with thus far anyway, private practices that are
insurance based.
So I don't have too, too much experience
working with the, the self pay.
However, what I will say is, I think
regardless of who your payer is, you know,
(10:20):
if it's self pay, if it's insurance, if
it's nonprofit, I think we need to look
at like, what do we need to do
in order to provide the best care possible?
I think lots of people think that, that
those notes in the documentation is for the
payer.
And yes, that's accurate.
That is true.
But I also have always taken the stance
(10:40):
that like, this is kind of for me,
this is my moment.
Now, do I always treat it so like
fluffy and positively?
No.
But when I, when I do find myself
getting like, ah, so many notes, I need
to get this done.
I try to sit back and just think
and reflect like this is for me to
conceptualize what has happened within the session.
Where do I think I'm headed next?
(11:02):
Have I been checking in about the goals?
Have I not?
Like, do I need to do a check
-in about that?
So I think, you know, if every clinician
could kind of lean more into that mindset
of like this being more for us than
having to follow all of these different requirements,
I think that we would trend in a
better direction in terms of documentation and just
be more open to documentation.
(11:24):
I think whether you're private pay, whether you're
insurance-based, like you should be taking good
notes because at the end of the day,
like if something were to happen, if it
wasn't written, you don't have a leg to
stand on.
So that in and of itself is like,
this documentation is for you to make sure
that you're protecting yourself in the event that,
you know, something, something catastrophic or, you know,
(11:44):
even just something minor were to happen.
You want to be able to have something
to point to that says, hey, you know,
this happened.
We had this conversation.
This was the agreement.
Otherwise, what are you going to do?
Yeah.
So what are some common mistakes that you
see people making in their documentation?
(12:05):
I think the biggest one is timeliness.
And it makes sense, right?
Because we are seeing clients back to back
to back to back multiple days in a
row.
And all it takes is that one day,
you know, where maybe you're not feeling your
best, maybe you're not as motivated, maybe you
can't focus.
And suddenly you have, you know, six, seven
notes, five notes, even to start your next
(12:26):
day.
And then, you know, you start the next
day, you're getting behind.
And, you know, we all know how that
process can start and kind of repeat itself.
So I think all it takes is just
that, that one day, and then we are
behind.
And that can become a pattern.
And also, you know, just for some people,
they're very good about getting those notes in
(12:47):
within the, you know, industry standard 24 to
48 hours.
And for others, like, it's just, it's always
been a weak point.
And that's okay.
We acknowledge that.
We give the skills to work on time
management, improving that a little bit.
But I would definitely say, like, timeliness, that
sticks out time and time again, as one
of the biggest errors or, like, weak points,
(13:09):
I think, for clinicians as a whole.
In addition to that, I would also say
miscoding.
So if you are an insurance-based practice,
I think that this probably more often than
not happens by accident.
You know, just it is hard to keep
track of time and how long was I
in the session and documenting that appropriately?
(13:30):
And did I start right on time?
Did I start two minutes later?
Did I write that I started at 1202
and not 12 o'clock?
Or did I just leave it as the
default?
And then, you know, if that session was
53 minutes, did I code it as the
90837?
If it was 52 minutes, did I code
that as the 90837?
Right?
Like, we, I think we make those mistakes
(13:51):
sometimes, because we're just moving a little bit
too fast.
But there's also, like, the intentional, you know,
it was 52 minutes, and I'm going to
code it as a 90837, right?
So just having to be super mindful and
intentional about keeping track of time and honest
reporting of our time and our duration spent
in session.
And, you know, thirdly, I would say biggest,
(14:14):
like, error is just proofreading.
This, I am big on, you know, proofreading,
editing things before we put it out there.
And I think especially so, even though, you
know, we're doing so many notes and lots
of times, like, no one is going to
read them besides you.
I think it's super important to just, at
the very minimum, give that quick glance over
to make sure, like, do you at least
(14:36):
have the client's name spelled right if you're
using client's names, right?
Can we at least make sure that that's
happening?
But, you know, lots of times we can
catch just really silly errors, and not that
it has to be perfect 100% of
the time, but can we, can we catch
the glaring stuff by doing a quick glance
over?
Yeah.
Can we talk about the risk involved with
each of these things?
What's the risk involved with the timeliness piece?
(14:59):
Like, let's say you're somebody who, like, most
of the time gets all your paperwork done
on Friday, but not all the time.
Like, what's the risk that we're putting ourselves
in?
Yeah.
Well, I think it's, you know, what you
mentioned a little bit ago with clawbacks, that
that is always a risk for many different
facets of our documentation if we're not doing
(15:20):
it according to standard.
Insurance can come back and say, you know,
hey, you didn't do this within the 48
hours or the 24 hours that we require,
and so, you know, we want our money
back for that session.
I would say, you know, by and large,
most therapists are like what you described, where
they're getting their notes done, they're getting the
(15:40):
documentation in on time.
They might have a day or two here
and there where it's like, ooh, that it
just didn't happen.
And there, you know, there's still risk there.
However, if I were in front of, like,
an insurance company, there was an audit happening,
I would point to like, look, this is
not a practice for this therapist.
You know, clearly there was something going on
(16:01):
that day to see if we can kind
of like mitigate risk.
Here's the things that we do to train
our clinicians to be better with time management.
Here's a plan that we could put in
place with this therapist if this were to
happen again.
So, always a risk that you carry, but
I think that there is ways even in
those cases where, like, this isn't normal or
common for a particular therapist, and it just
(16:21):
happened, and it just happened to be caught.
I think there's still ways to try to
mitigate the risk, if not for that particular
maybe, like, session that's being audited, then in
the future, right, to mitigate the risks moving
forward.
And I think about, like, the people listening
who are group practice owners or the people
who are listening who are in group practice,
(16:41):
like, it really does underscore how important that
timeliness is.
If, you know, I've worked with group practice
centers who had $30,000 clawbacks, and if
the clawback happened partly because notes were turned
in four days late or two weeks late,
like, that's a shit ton of money that
the practice no longer has, and that they
(17:04):
might not be able to stay open because
typically group practices don't have a huge profit
margin.
So, hopefully for anybody who is currently working
in a group practice, that's a little nudge
to get those things done, and for those
who own the group practice, it's a reminder
of, like, make sure your clinicians are doing
that so that you don't get into a
position where you maybe can't even keep your
(17:24):
business open anymore.
Absolutely, yeah, and I like that you throw
in that perspective because, you know, as the
clinician employed in a group practice myself, like,
it gives me another level of respect for,
like, my responsibilities.
Like, this isn't just about making sure that
I get a paycheck at the end of
the day.
Like, it is about the stability and viability
(17:48):
of the practice as a whole, and, you
know, if my employer has given me the
opportunity to be employed here and have many
opportunities within that employment, I want to make
sure that I'm doing what I can to
help myself stay afloat, but to help the
practice stay afloat, to help my colleagues stay
afloat because you're so right.
Like, it just takes a few clawbacks, and
(18:10):
that could be the end of the business,
which is devastating.
Yeah, absolutely.
I'm assuming similar risk for both coding and
proofreading that, like, if you've miscoded, and, like,
there's the coding that they're never going to
know about.
Like, if you went 52 minutes and you
wrote that it's a 90837, they're unlikely to
know about that, but we gotta have integrity,
(18:33):
you know?
Like, just go another minute or just do
a 90834.
Yeah.
And so trusting that everybody listening has integrity,
the coding errors and the proofreading problems could
lead to clawbacks as, like, the primary risk
involved there.
Yeah, for sure, and I think, you know,
(18:54):
I was just involved in a conversation yesterday,
a consultation just talking a little bit about,
like, the miscoding, and it truly was just
an error, right?
And what it boiled down to was, like,
okay, in the future, like, let's just slow
down.
That's all it would probably take to just
slow down before you hit that sign button,
make sure that those numbers match.
Like, yes, those seconds add up over time,
(19:16):
over the day, but those seconds could really
mean the difference between, like we were just
talking about, does the practice stay open or
does it not?
Do you stay employed or do you not?
And that's not to, last piece there is
not to say, like, if you miscode, you're
going to lose your job.
Like, I'm not in charge of that for
anyone, but part of what I do in
(19:37):
my consultations is try to really, like, offload
the fear, so I recognize that as, like,
a very fear-loaded statement, but I do
think it's important to just consider, like, yeah,
how my quickness, my swiftness through my documentation
when I'm not paying attention to maybe different
errors that I might be making, how it
could really have some detrimental outcomes.
(19:57):
Likelihood, maybe slim with the large volume of
documentation being produced in a given day by,
you know, any given practice, but still, it's
risk.
Absolutely.
I'm thinking, too, about the whole private pay
question.
If you're doing out-of- network benefits,
if you're sending people, like, if the super
(20:17):
bill is getting to the insurance company, then
you are required to meet their needs, basically.
If they're paying that client back for that
session, they can call that back from the
client if you are not doing the notes
that you need to do.
Yeah.
So just putting that in there for folks.
(20:37):
What else?
What else are we missing with documentation that,
like, would make it better, cleaner, easier for
everyone involved?
You know, I think I see a lot
of times some of these errors being made,
perhaps in part due to just, like, unclear
guidelines.
I think especially when you're into private practice,
(20:59):
it's like, oh, what do I do?
I remember having those questions when I started
in group practice of, like, I know how
to write a treatment plan, but what's required?
Like, I've only had experience in partial hospitalization.
I've only had experience in nonprofit.
So what do I need to do in
terms of private practice?
What do insurance companies want from me?
So I think that is, like, 50%
(21:21):
of the equation here, where, you know, if
you're in private practice, are you supplying your
clinicians with, like, a roadmap or a blueprint
for what do they need to even include
in their documentation?
Once you provide that, right, you get to
say, like, you were given the criteria, you
were given that blueprint, and that is what
(21:41):
is expected of you.
I think the other, like, 50% of
the equation is clinician confidence.
You know, I think sometimes, like, that over
-documentation especially comes from, like, well, I just
don't know what to include, and so I
include it all, right?
Or, you know, the under-documentation could be
some of that too.
Like, I don't know what to include, so
I just include the bare bones because I
(22:03):
don't want to put in too much.
And I think we need to fall back
on, like, we all go through extensive training
to get in this position that we're in.
We, you know, most of us are licensed
or pursuing that licensure.
We have to do continuing education.
We know what we're doing, and I think
a lot of times we get scared, especially
when that word, like, compliance is thrown around.
(22:25):
Like, oh, gosh, they're going to do chart
audits, and we get really nervous about are
we doing the right thing or are we
not?
And fall back on your training.
You've had extensive training in how to do
this.
You know how to do this.
You have a clinical gut, right?
We talk about that, like, trust your clinical
gut.
Does it feel like it needs to be
in the note?
Yes, include it.
Does it feel like it shouldn't because it
might be a detriment to the client's safety
(22:46):
or well-being?
Then no, don't include that, right?
So, yeah, I would say that that is
an important piece that I don't often hear
talked about, like, just being able to trust
yourself in what you are documenting.
And when you are really struggling, that's why
we have supervision.
Yeah.
And I think about, like, I'm somebody who
loves an example.
I'm someone who loves a structure.
(23:08):
Like, when I worked in different places who
either did soap notes or burp notes and
being like, could somebody just tell me which
one to do?
Like, I just, I don't care.
Just give me a structure.
Give me an example.
And I feel like that's missing.
To my knowledge, I don't know of any
insurance companies who provide that.
Like, we expect your notes to look like
(23:28):
this, but then they can pull our money
back when we haven't done it the way
they haven't told us how to do it.
Yes.
So how do solo private practice folks figure
that out if they take insurance when insurance
isn't telling us what we're going to get
dinged for?
Yeah, I'm going to give an answer.
And I think people might turn off the
(23:51):
podcast at this point in time, but I'm
going to give the answer anyway, because it
was what was most helpful to me.
And that is reading the insurance manuals.
Oh, yes.
I know.
It's not the most fun reading, but it
really does spell out everything that we need
to include in there now in way too
(24:13):
many pages and with way too much detail
that really doesn't apply to us, right?
Because they just hand us the whole manual,
whether it's applicable to physical health, mental health.
But if you kind of sit down with
those manuals, you will be able to create
that blueprint for yourself.
You will be able to create, you know,
they need this and this and this, and
the intake should include this.
(24:34):
The treatment plan should look like this.
And then, you know, you can kind of
create those examples for yourself or a template
or an outline or something of what each
of those pieces of documentation should look like.
But yeah, not the prettiest answer there, but
I think it is a tool at our
disposal.
Now, could insurance companies get a little bit
(24:55):
better at providing us with, you know, a
one pager, a good example?
Yes.
I would advocate for that 100%.
Yeah.
Yeah.
It's almost like they're just fine with it
being obtuse.
Yes.
Yeah.
Which they make more money that way.
I get it.
Yeah.
All right.
Anything else we're missing around document?
(25:16):
Oh, AI notes.
What is your opinion on AI notes?
Oh, yes.
This is a hot topic right now.
You know, I think we just don't know
enough.
We don't know enough about where the data
is being stored.
We don't know enough about what happens to
that data.
We don't have training and how to sit
(25:39):
down.
And if, you know, if we are going
to use some sort of AI software to
produce the note, like I've seen it done
in action and it's pretty scary how one
sentence can turn into an entire progress note,
right?
Like you feed it one sentence and it
automatically tells you like all of these details
that's like, how did it know anything?
And it's obvious that we should go back
(26:01):
and make sure that we're looking to see
that those things are accurate, but also without
the training, we can't assume that people would
know to go back and make sure that
those details are accurate.
So I personally am kind of taking a
firm stance, you know, until we know more,
it's probably not the best to be integrating
in until we have access to training.
(26:22):
It's probably not the best to be integrating
in.
And if you have had access to training,
then, you know, then okay.
I just myself haven't come across any or
feel comfortable doing that myself or recommending that
to other people because we just don't, we
don't have regulation around it at this point
in time.
Yeah.
Yeah.
And I think about how it comes back
(26:44):
to the timeliness, the coding, the proofreading, like
the proofreading is a really important piece because
like you said, one sentence can be taken
way into left field.
And I mean, I don't know how good
AI is and if it can distinguish voices
between people who have very similar voices or
whatever, you know, like how it works.
(27:05):
So just making sure if you are somebody
who's using AI, that you're not just copy
pasting into your EHR or it's not just
hitting except if it's within your EHR, that
you're reading it and you're making sure that
it hits all those pieces that we talked
about, making sure that it talks about the
time you started in making sure that it
talks about medical necessity, the person, how the
person's goals are being worked on through what
(27:28):
treatment modalities or, or interventions.
Cause I mean, it just depends on the
AI.
I'm sure that some can do that for
you, but you still need to make sure
that what they say happened in session happened
in session.
Yeah.
And I think it's obvious anyway, going to
continue trending in that direction, building more AI
into EHRs.
So it's, it's kind of like a here
(27:49):
to stay situation.
And I think you're highlighting about the importance
of reviewing the note is kind of the
equivalent to, you know, up until this point,
we've been writing the notes ourselves.
And like I mentioned earlier, that for me
anyway, is kind of my time to conceptualize
the case.
At the very minimum, we, we need to
be reviewing to make sure we have all
(28:10):
of these different pieces, but also to continue
conceptualizing the case to continue thinking about what
is even happening in this client's treatment.
Do they still need treatment?
Right.
These are questions that should be floating around
in your mind as you're doing, you know,
note after note treatment plan after treatment plan
for clients.
Yeah.
Amazing.
Thank you so much, Tiana.
(28:31):
I feel like this is like very actionable,
so I would love people to take this
and like take care of themselves notes wise.
Yes.
Yes.
That's the hope.
That's the hope.
And if you read the insurance manual in
the process, then I guess my job is
done here.
Yeah.
Amazing.
Yeah.
And our condolences if you do.
(28:55):
Awesome.
Well, thank you so much.
And yeah, if folks want to get in
touch, privatepracticebydesign.com is where they can get
some more.
So thank you so much.
Absolutely.
Thank you so much for having me.
Make sure your email is actually HIPAA compliant
with Powebox use code abundant to get Powebox
(29:16):
for less than a hundred dollars your first
year at P-A-U-B-O-X
dot com.
If you're ready for a much easier practice,
therapy notes is the way to go.
Go to therapy notes.com and use the
promo code abundant for two months free.
If you're listening, you probably need some support
(29:38):
building your practice.
If you're a super newbie, grab our free
checklist using the link in the show notes.
I'd love for you to follow rate and
review, but I really want you to share
this episode with a therapist friend.
Let's help all our colleagues build what they
want.
(Transcribed by TurboScribe.ai. Go Unlimited to remove this message.) Hi, welcome to the Abundant Practice Podcast.
I'm Allison from Abundance Practice Building.
I have a nearly diagnosable obsession with helping
therapists build sustainable, joy-filled private practices, just
like I've done for tens of thousands of
therapists across the world.
I'm excited to help you too.
If you want to fill your practice with
ideal clients, we have loads of free resources
(00:29):
and paid support.
Go to abundancepracticebuilding.com slash links.
All right, on to the show.
Some of y'all aren't sending HIPAA-compliant
email, and it's a problem.
Even if you're paying for a business Google
Workspace account and have a signed BAA, your
emails still aren't 100% compliant.
That's where Powerbox comes in.
(00:50):
You can connect Powerbox to your Google Workspace
or Microsoft 365 email one time, and you're
completely covered.
No one has to sign into portals, it
sends, and it shows up like any other
email.
Behind the scenes, Powerbox software checks the security
settings of the recipient and ensures that the
email is sent properly, so you're not violating
HIPAA in the ways you may accidentally be
(01:10):
now.
I know, HIPAA isn't sexy, but we don't
avoid compliance in an abundant practice.
We check the boxes we need to check,
and this is the easiest way to do
that with email.
Check out my friends at powerbox.com, that's
P-A-U-B-O-X.
Use code abundant to get $250 off your
first year of Powerbox.
That makes it less than $100 for your
(01:31):
first year.
Again, that's P-A-U-B-O-X
.com.
Use code abundant.
I've talked about therapy notes on here for
years.
I could talk about the features and the
benefits in my sleep, but there are a
couple of things I want you to know
about therapy notes that doesn't typically make it
into an ad script.
First is that they actually care if you
like their platform.
(01:52):
They don't only make themselves available on the
phone to troubleshoot so you don't pull your
hair out when you get stuck.
They also take member suggestions and implement those
that there's client demand for, like therapy search,
an included listing service that helps clients find
you, internal and external secure messaging, clinical outcome
measures to keep an eye on how your
clients are progressing, a super smooth super bill
(02:13):
process, real-time eligibility to check on your
client's insurance.
In my conversations with the employees there at
all levels, they all really believe in their
product and they want you to love it
too.
Second, they are proudly independently owned.
Why should you care about that?
Because as soon as venture capital becomes involved,
the focus shifts from making customers happy to
(02:34):
making investors happy.
Prices go way up, innovation plateaus, making more
money with as little output as possible becomes
the number one focus.
With over 100,000 therapists using their platform,
they've been able to stay incredibly successful and
they don't have to sacrifice your experience to
stay there.
You can try two months free at therapynotes
(02:54):
.com with the coupon code ABUNDANT.
Welcome back to the Abundant Practice Podcast.
I'm your host, Alison Puryear.
I'm here with Tiana Kelly, and we are
going to be talking about notes one-on
-one.
Your notes are really important.
We know they're important.
None of us are super on fire, excited
about them.
You're probably going to want to check out
(03:16):
privatepracticebydesign.com after this conversation so that you
can get some more of what Tiana's talking
about.
Thanks for being here, Tiana.
Of course.
Yes.
Thanks for having me.
I'm super excited to dive into this conversation.
You said, it's not the most glamorous or
we're not going to have the most fun
time doing our notes, but talking about it
and making sure that we're all practicing within
(03:38):
best practice recommendations is, I think, super important
for our field, even when we don't like
to admit it.
Yeah, absolutely.
I think right now I have heard from
a lot of students who take insurance that
there's across the country in the US a
rash of clawbacks that have been happening, and
that's often due to documentation.
(03:59):
We really want to make sure that documentation
is as buttoned up as it can be,
even though none of us are like, gosh,
I wish I could do more of that.
What would you say are the basics of
what we absolutely need to have in every
single note?
Oh, that's a really good question.
(04:21):
Obviously, every EHR is going to set us
up a little bit differently for what gets
included in the note, but I think by
and large, the trends are we want to
have some data on our observations.
So you think about kind of that mental
status exam data.
I think that across the board is consistent
(04:41):
for EHRs, for how we were trained as
therapists.
What are we observing from the client in
terms of some of that mental status?
I also think our payers, specifically if you're
an insurance-based practice, they want to see
like what are the interventions we're using and
how are those interventions connected to like the
(05:02):
goal work.
They want to see evidence that the goals
are being worked on within the notes.
What's the plan?
What's the plan between sessions?
What's the plan for, you know, if you
have a tentative agenda for your next session,
how are you going to follow up about
some of the information that was maybe talked
about at the last session?
So that's kind of like the meat of,
I think, the important pieces that need to
(05:24):
be within notes, within our documentation.
Of course, there's like the logistics, making sure
that we're coding sessions correctly and capturing like
accurate times within the sessions.
So yeah, I would say that in a
nutshell, a really quick nutshell, that those would
be some of the most important pieces to
make sure we're focusing on.
And I think about like medical necessity, how
(05:47):
do those things prove medical necessity?
Yes.
Yeah, this is a big thing that I
am working on within our practice to like
strengthen our documentation around how we're trying to
prove or give evidence to some of that
medical necessity, making sure that we're finding ways
to justify what diagnoses we're providing, you know,
making sure that we're, sometimes it's going back
(06:08):
and pulling out that DSM and looking at
what criteria is the client giving me that
matches a specific diagnosis?
And then, you know, use that DSM as
your tool to write up that presenting problem,
to justify, yep, this is the diagnosis that
I'm providing or to justify, yep, these are
the goals that need to be worked on.
So yeah, I like that you bring that
(06:28):
point up because it is, it's a huge
sticking point when it comes to insurance.
And I think it does, if we do
it correctly, help to really guide our work,
our diagnosis and our treatment.
Yeah, when I was coming up as a
social worker, I went from doing like really
arduously long notes that were basically like a
rehashing of the entire session.
(06:49):
And one type of place, that's how we
were kind of trained to do our notes,
to working at a sexual assault center and
child advocacy center where our notes were likely
going to court in many circumstances.
So they became very skeletal.
And like, as long as I checked the
boxes, we didn't, we were a nonprofit, so
we didn't have to contend with insurance.
But like, to check enough boxes, while maintaining
(07:11):
enough privacy for the client, it was like
this really intricate balance of being skeletal, but
also meeting the needs of what documentation is
supposed to provide.
Where do you fall on like the skeletal
notes versus rehashing of the session?
Excellent question.
I love that you're bringing this up because
(07:31):
I, it sounds like we have very similar
backgrounds in terms of, you know, work and
where we've gotten started.
And I have, my initial training, my internship
was at a domestic violence, sexual violence agency.
So we were very skeletal.
And then I moved into partial hospitalization, and
that was give me every single detail of
(07:52):
every client every single day.
So it is a really strong skill set
you have to develop in order to get
a little bit of both, right?
Keep the detail in there when it's relevant
and important, but also cut out the fluff
when you really just don't need it, or
when it might be a detriment to the
client, to the client's safety, to the client's
(08:13):
care.
I, whenever I'm working with clinicians, you know,
in consultation about their documentation, that is the
first question that I ask them if I
don't already know that about them is, you
know, give me a sense of where you
got started in your practice, in your counseling
practice, because it does help me to understand
when I'm in there looking at their files,
and if they have really scant documentation versus
(08:36):
really, really wordy, giving me every single detail,
a lot of times I can kind of
trace that back to what their work experiences
have been thus far, you know, those ones
that it's, there's barely any detail in there.
They have had some kind of work experience,
like in some like victim services agency, which
helps me then to know like, okay, this
(08:57):
is where this is coming from.
It's not just because you don't want to
do documentation, like we can kind of cut
those judgments out.
If we just sit down and have a
conversation around like, what have your work experiences
been?
What has your training been like?
And then how now that we're in private
practice, and our payers have their own requirements,
how do we find a balance between the
two, you know, to honor like where you
(09:17):
think it's appropriate to keep the details out,
but also make sure that we're providing enough
detail that we can, for instance, justify the
treatment that's happening.
Absolutely.
And I'm curious, because we're, so we're talking
about these different workplaces, some are beholden to
insurance companies, some are not.
(09:38):
I think about this, the way some private
pay clinicians approach their notes is kind of
like, I don't really need to do this.
Like I'm not going to get audited by
an insurance company and have to pay money
back.
What is the difference in documentation from an
ethics perspective for private pay clinicians versus clinicians
(09:59):
who take insurance?
So primarily when, when I'm consulting, I'm consulting
with thus far anyway, private practices that are
insurance based.
So I don't have too, too much experience
working with the, the self pay.
However, what I will say is, I think
regardless of who your payer is, you know,
(10:20):
if it's self pay, if it's insurance, if
it's nonprofit, I think we need to look
at like, what do we need to do
in order to provide the best care possible?
I think lots of people think that, that
those notes in the documentation is for the
payer.
And yes, that's accurate.
That is true.
But I also have always taken the stance
(10:40):
that like, this is kind of for me,
this is my moment.
Now, do I always treat it so like
fluffy and positively?
No.
But when I, when I do find myself
getting like, ah, so many notes, I need
to get this done.
I try to sit back and just think
and reflect like this is for me to
conceptualize what has happened within the session.
Where do I think I'm headed next?
(11:02):
Have I been checking in about the goals?
Have I not?
Like, do I need to do a check
-in about that?
So I think, you know, if every clinician
could kind of lean more into that mindset
of like this being more for us than
having to follow all of these different requirements,
I think that we would trend in a
better direction in terms of documentation and just
be more open to documentation.
(11:24):
I think whether you're private pay, whether you're
insurance-based, like you should be taking good
notes because at the end of the day,
like if something were to happen, if it
wasn't written, you don't have a leg to
stand on.
So that in and of itself is like,
this documentation is for you to make sure
that you're protecting yourself in the event that,
you know, something, something catastrophic or, you know,
(11:44):
even just something minor were to happen.
You want to be able to have something
to point to that says, hey, you know,
this happened.
We had this conversation.
This was the agreement.
Otherwise, what are you going to do?
Yeah.
So what are some common mistakes that you
see people making in their documentation?
(12:05):
I think the biggest one is timeliness.
And it makes sense, right?
Because we are seeing clients back to back
to back to back multiple days in a
row.
And all it takes is that one day,
you know, where maybe you're not feeling your
best, maybe you're not as motivated, maybe you
can't focus.
And suddenly you have, you know, six, seven
notes, five notes, even to start your next
(12:26):
day.
And then, you know, you start the next
day, you're getting behind.
And, you know, we all know how that
process can start and kind of repeat itself.
So I think all it takes is just
that, that one day, and then we are
behind.
And that can become a pattern.
And also, you know, just for some people,
they're very good about getting those notes in
(12:47):
within the, you know, industry standard 24 to
48 hours.
And for others, like, it's just, it's always
been a weak point.
And that's okay.
We acknowledge that.
We give the skills to work on time
management, improving that a little bit.
But I would definitely say, like, timeliness, that
sticks out time and time again, as one
of the biggest errors or, like, weak points,
(13:09):
I think, for clinicians as a whole.
In addition to that, I would also say
miscoding.
So if you are an insurance-based practice,
I think that this probably more often than
not happens by accident.
You know, just it is hard to keep
track of time and how long was I
in the session and documenting that appropriately?
(13:30):
And did I start right on time?
Did I start two minutes later?
Did I write that I started at 1202
and not 12 o'clock?
Or did I just leave it as the
default?
And then, you know, if that session was
53 minutes, did I code it as the
90837?
If it was 52 minutes, did I code
that as the 90837?
Right?
Like, we, I think we make those mistakes
(13:51):
sometimes, because we're just moving a little bit
too fast.
But there's also, like, the intentional, you know,
it was 52 minutes, and I'm going to
code it as a 90837, right?
So just having to be super mindful and
intentional about keeping track of time and honest
reporting of our time and our duration spent
in session.
And, you know, thirdly, I would say biggest,
(14:14):
like, error is just proofreading.
This, I am big on, you know, proofreading,
editing things before we put it out there.
And I think especially so, even though, you
know, we're doing so many notes and lots
of times, like, no one is going to
read them besides you.
I think it's super important to just, at
the very minimum, give that quick glance over
to make sure, like, do you at least
(14:36):
have the client's name spelled right if you're
using client's names, right?
Can we at least make sure that that's
happening?
But, you know, lots of times we can
catch just really silly errors, and not that
it has to be perfect 100% of
the time, but can we, can we catch
the glaring stuff by doing a quick glance
over?
Yeah.
Can we talk about the risk involved with
each of these things?
What's the risk involved with the timeliness piece?
(14:59):
Like, let's say you're somebody who, like, most
of the time gets all your paperwork done
on Friday, but not all the time.
Like, what's the risk that we're putting ourselves
in?
Yeah.
Well, I think it's, you know, what you
mentioned a little bit ago with clawbacks, that
that is always a risk for many different
facets of our documentation if we're not doing
(15:20):
it according to standard.
Insurance can come back and say, you know,
hey, you didn't do this within the 48
hours or the 24 hours that we require,
and so, you know, we want our money
back for that session.
I would say, you know, by and large,
most therapists are like what you described, where
they're getting their notes done, they're getting the
(15:40):
documentation in on time.
They might have a day or two here
and there where it's like, ooh, that it
just didn't happen.
And there, you know, there's still risk there.
However, if I were in front of, like,
an insurance company, there was an audit happening,
I would point to like, look, this is
not a practice for this therapist.
You know, clearly there was something going on
(16:01):
that day to see if we can kind
of like mitigate risk.
Here's the things that we do to train
our clinicians to be better with time management.
Here's a plan that we could put in
place with this therapist if this were to
happen again.
So, always a risk that you carry, but
I think that there is ways even in
those cases where, like, this isn't normal or
common for a particular therapist, and it just
(16:21):
happened, and it just happened to be caught.
I think there's still ways to try to
mitigate the risk, if not for that particular
maybe, like, session that's being audited, then in
the future, right, to mitigate the risks moving
forward.
And I think about, like, the people listening
who are group practice owners or the people
who are listening who are in group practice,
(16:41):
like, it really does underscore how important that
timeliness is.
If, you know, I've worked with group practice
centers who had $30,000 clawbacks, and if
the clawback happened partly because notes were turned
in four days late or two weeks late,
like, that's a shit ton of money that
the practice no longer has, and that they
(17:04):
might not be able to stay open because
typically group practices don't have a huge profit
margin.
So, hopefully for anybody who is currently working
in a group practice, that's a little nudge
to get those things done, and for those
who own the group practice, it's a reminder
of, like, make sure your clinicians are doing
that so that you don't get into a
position where you maybe can't even keep your
(17:24):
business open anymore.
Absolutely, yeah, and I like that you throw
in that perspective because, you know, as the
clinician employed in a group practice myself, like,
it gives me another level of respect for,
like, my responsibilities.
Like, this isn't just about making sure that
I get a paycheck at the end of
the day.
Like, it is about the stability and viability
(17:48):
of the practice as a whole, and, you
know, if my employer has given me the
opportunity to be employed here and have many
opportunities within that employment, I want to make
sure that I'm doing what I can to
help myself stay afloat, but to help the
practice stay afloat, to help my colleagues stay
afloat because you're so right.
Like, it just takes a few clawbacks, and
(18:10):
that could be the end of the business,
which is devastating.
Yeah, absolutely.
I'm assuming similar risk for both coding and
proofreading that, like, if you've miscoded, and, like,
there's the coding that they're never going to
know about.
Like, if you went 52 minutes and you
wrote that it's a 90837, they're unlikely to
know about that, but we gotta have integrity,
(18:33):
you know?
Like, just go another minute or just do
a 90834.
Yeah.
And so trusting that everybody listening has integrity,
the coding errors and the proofreading problems could
lead to clawbacks as, like, the primary risk
involved there.
Yeah, for sure, and I think, you know,
(18:54):
I was just involved in a conversation yesterday,
a consultation just talking a little bit about,
like, the miscoding, and it truly was just
an error, right?
And what it boiled down to was, like,
okay, in the future, like, let's just slow
down.
That's all it would probably take to just
slow down before you hit that sign button,
make sure that those numbers match.
Like, yes, those seconds add up over time,
(19:16):
over the day, but those seconds could really
mean the difference between, like we were just
talking about, does the practice stay open or
does it not?
Do you stay employed or do you not?
And that's not to, last piece there is
not to say, like, if you miscode, you're
going to lose your job.
Like, I'm not in charge of that for
anyone, but part of what I do in
(19:37):
my consultations is try to really, like, offload
the fear, so I recognize that as, like,
a very fear-loaded statement, but I do
think it's important to just consider, like, yeah,
how my quickness, my swiftness through my documentation
when I'm not paying attention to maybe different
errors that I might be making, how it
could really have some detrimental outcomes.
(19:57):
Likelihood, maybe slim with the large volume of
documentation being produced in a given day by,
you know, any given practice, but still, it's
risk.
Absolutely.
I'm thinking, too, about the whole private pay
question.
If you're doing out-of- network benefits,
if you're sending people, like, if the super
(20:17):
bill is getting to the insurance company, then
you are required to meet their needs, basically.
If they're paying that client back for that
session, they can call that back from the
client if you are not doing the notes
that you need to do.
Yeah.
So just putting that in there for folks.
(20:37):
What else?
What else are we missing with documentation that,
like, would make it better, cleaner, easier for
everyone involved?
You know, I think I see a lot
of times some of these errors being made,
perhaps in part due to just, like, unclear
guidelines.
I think especially when you're into private practice,
(20:59):
it's like, oh, what do I do?
I remember having those questions when I started
in group practice of, like, I know how
to write a treatment plan, but what's required?
Like, I've only had experience in partial hospitalization.
I've only had experience in nonprofit.
So what do I need to do in
terms of private practice?
What do insurance companies want from me?
So I think that is, like, 50%
(21:21):
of the equation here, where, you know, if
you're in private practice, are you supplying your
clinicians with, like, a roadmap or a blueprint
for what do they need to even include
in their documentation?
Once you provide that, right, you get to
say, like, you were given the criteria, you
were given that blueprint, and that is what
(21:41):
is expected of you.
I think the other, like, 50% of
the equation is clinician confidence.
You know, I think sometimes, like, that over
-documentation especially comes from, like, well, I just
don't know what to include, and so I
include it all, right?
Or, you know, the under-documentation could be
some of that too.
Like, I don't know what to include, so
I just include the bare bones because I
(22:03):
don't want to put in too much.
And I think we need to fall back
on, like, we all go through extensive training
to get in this position that we're in.
We, you know, most of us are licensed
or pursuing that licensure.
We have to do continuing education.
We know what we're doing, and I think
a lot of times we get scared, especially
when that word, like, compliance is thrown around.
(22:25):
Like, oh, gosh, they're going to do chart
audits, and we get really nervous about are
we doing the right thing or are we
not?
And fall back on your training.
You've had extensive training in how to do
this.
You know how to do this.
You have a clinical gut, right?
We talk about that, like, trust your clinical
gut.
Does it feel like it needs to be
in the note?
Yes, include it.
Does it feel like it shouldn't because it
might be a detriment to the client's safety
(22:46):
or well-being?
Then no, don't include that, right?
So, yeah, I would say that that is
an important piece that I don't often hear
talked about, like, just being able to trust
yourself in what you are documenting.
And when you are really struggling, that's why
we have supervision.
Yeah.
And I think about, like, I'm somebody who
loves an example.
I'm someone who loves a structure.
(23:08):
Like, when I worked in different places who
either did soap notes or burp notes and
being like, could somebody just tell me which
one to do?
Like, I just, I don't care.
Just give me a structure.
Give me an example.
And I feel like that's missing.
To my knowledge, I don't know of any
insurance companies who provide that.
Like, we expect your notes to look like
(23:28):
this, but then they can pull our money
back when we haven't done it the way
they haven't told us how to do it.
Yes.
So how do solo private practice folks figure
that out if they take insurance when insurance
isn't telling us what we're going to get
dinged for?
Yeah, I'm going to give an answer.
And I think people might turn off the
(23:51):
podcast at this point in time, but I'm
going to give the answer anyway, because it
was what was most helpful to me.
And that is reading the insurance manuals.
Oh, yes.
I know.
It's not the most fun reading, but it
really does spell out everything that we need
to include in there now in way too
(24:13):
many pages and with way too much detail
that really doesn't apply to us, right?
Because they just hand us the whole manual,
whether it's applicable to physical health, mental health.
But if you kind of sit down with
those manuals, you will be able to create
that blueprint for yourself.
You will be able to create, you know,
they need this and this and this, and
the intake should include this.
(24:34):
The treatment plan should look like this.
And then, you know, you can kind of
create those examples for yourself or a template
or an outline or something of what each
of those pieces of documentation should look like.
But yeah, not the prettiest answer there, but
I think it is a tool at our
disposal.
Now, could insurance companies get a little bit
(24:55):
better at providing us with, you know, a
one pager, a good example?
Yes.
I would advocate for that 100%.
Yeah.
Yeah.
It's almost like they're just fine with it
being obtuse.
Yes.
Yeah.
Which they make more money that way.
I get it.
Yeah.
All right.
Anything else we're missing around document?
(25:16):
Oh, AI notes.
What is your opinion on AI notes?
Oh, yes.
This is a hot topic right now.
You know, I think we just don't know
enough.
We don't know enough about where the data
is being stored.
We don't know enough about what happens to
that data.
We don't have training and how to sit
(25:39):
down.
And if, you know, if we are going
to use some sort of AI software to
produce the note, like I've seen it done
in action and it's pretty scary how one
sentence can turn into an entire progress note,
right?
Like you feed it one sentence and it
automatically tells you like all of these details
that's like, how did it know anything?
And it's obvious that we should go back
(26:01):
and make sure that we're looking to see
that those things are accurate, but also without
the training, we can't assume that people would
know to go back and make sure that
those details are accurate.
So I personally am kind of taking a
firm stance, you know, until we know more,
it's probably not the best to be integrating
in until we have access to training.
(26:22):
It's probably not the best to be integrating
in.
And if you have had access to training,
then, you know, then okay.
I just myself haven't come across any or
feel comfortable doing that myself or recommending that
to other people because we just don't, we
don't have regulation around it at this point
in time.
Yeah.
Yeah.
And I think about how it comes back
(26:44):
to the timeliness, the coding, the proofreading, like
the proofreading is a really important piece because
like you said, one sentence can be taken
way into left field.
And I mean, I don't know how good
AI is and if it can distinguish voices
between people who have very similar voices or
whatever, you know, like how it works.
(27:05):
So just making sure if you are somebody
who's using AI, that you're not just copy
pasting into your EHR or it's not just
hitting except if it's within your EHR, that
you're reading it and you're making sure that
it hits all those pieces that we talked
about, making sure that it talks about the
time you started in making sure that it
talks about medical necessity, the person, how the
person's goals are being worked on through what
(27:28):
treatment modalities or, or interventions.
Cause I mean, it just depends on the
AI.
I'm sure that some can do that for
you, but you still need to make sure
that what they say happened in session happened
in session.
Yeah.
And I think it's obvious anyway, going to
continue trending in that direction, building more AI
into EHRs.
So it's, it's kind of like a here
(27:49):
to stay situation.
And I think you're highlighting about the importance
of reviewing the note is kind of the
equivalent to, you know, up until this point,
we've been writing the notes ourselves.
And like I mentioned earlier, that for me
anyway, is kind of my time to conceptualize
the case.
At the very minimum, we, we need to
be reviewing to make sure we have all
(28:10):
of these different pieces, but also to continue
conceptualizing the case to continue thinking about what
is even happening in this client's treatment.
Do they still need treatment?
Right.
These are questions that should be floating around
in your mind as you're doing, you know,
note after note treatment plan after treatment plan
for clients.
Yeah.
Amazing.
Thank you so much, Tiana.
(28:31):
I feel like this is like very actionable,
so I would love people to take this
and like take care of themselves notes wise.
Yes.
Yes.
That's the hope.
That's the hope.
And if you read the insurance manual in
the process, then I guess my job is
done here.
Yeah.
Amazing.
Yeah.
And our condolences if you do.
(28:55):
Awesome.
Well, thank you so much.
And yeah, if folks want to get in
touch, privatepracticebydesign.com is where they can get
some more.
So thank you so much.
Absolutely.
Thank you so much for having me.
Make sure your email is actually HIPAA compliant
with Powebox use code abundant to get Powebox
(29:16):
for less than a hundred dollars your first
year at P-A-U-B-O-X
dot com.
If you're ready for a much easier practice,
therapy notes is the way to go.
Go to therapy notes.com and use the
promo code abundant for two months free.
If you're listening, you probably need some support
(29:38):
building your practice.
If you're a super newbie, grab our free
checklist using the link in the show notes.
I'd love for you to follow rate and
review, but I really want you to share
this episode with a therapist friend.
Let's help all our colleagues build what they
want.
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