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Episode 155 | Mistakes Group Practice Owners Make when Teaching Documentation with Maelisa Hall

episode 46 getting quality notes from staff maelissa hall


  • Episode 155 | Mistakes Group Practice Owners Make when Teaching Documentation with Maelisa Hall 00:00


Hey Group Practice listeners! New podcast episode out today! In this episode, you’re getting a clip from a training from my Exchange Membership where Maelissa Hall talks about the top mistakes group practice owners make when teaching documentation to their staff.

In this episode we cover:
→ Common mistakes owners make
→ Why clinicians may struggle with documentation

This episode is sponsored by TherapyNotes. TherapyNotes is an EHR software that helps behavioral health professionals manage their practice with confidence and efficiency. I use TherapyNotes in my own group practice and love its amazing support team, billing features, and scheduling capabilities. It serves us well as a large group practice owner.

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Maureen Werrbach

Maureen Werrbach

Hello. All right. So today we’re going to be sharing a clip from the Exchange Membership site. It is an expert training done by Maelisa Hall. She’s the owner of QA Prep, which is all about documentation in private practice. And this is an oldie but goodie, which is why we pulled it out of the archive and are sharing it inside this podcast episode. But these few minute clips that we’re going to listen to is on five mistakes that practice owners make when it comes to documentation and their supervisors. And so I really loved this episode and want to share just this little clip here. If you’re a member of the exchange, you can jump into the exchange and watch the whole training. It’s called the art of teaching documentation. And if you’re not yet a member and want to watch the whole training, you can go to members dot the group practice exchange dot com and sign up and get in there and watch that training along with hundreds of other trainings. So let’s take a listen. And we’ll chat afterwards.

Maelisa Hall

All right, so let’s talk about some common mistakes of supervisors and just checking my time here.

So common mistake number one, thinking, well, they’re already licensed, they don’t need any training.

Part of the reason I got into doing this was that I was working in quality assurance at an agency. And we did–it was a very extensive training program. And that was how I learned like, oh, I really like doing trainings and giving trainings and and talking to people about the stuff. And the most common thing I heard across the board from everyone, whether they were a recent graduate, or whether they had been working somewhere else for 20 years was, thank God, we got this training, thank you so much. I’ve never been anywhere else or I’ve never gotten training on this ever. So never ever assume that you that your clinicians have had training at all, on any kind of documentation. Now, they may have had almost no training and still be pretty good at it, that’s fine. But you never want to assume that just because someone is licensed, because they’re a contractor because they have whatever a good reputation, that they are good at documentation or that they’re doing their documentation.

So common mistake number two. So “I gave them the training, they should know this already.”

Now really this is this is more a training mistake, right? Like as leaders, we should all know this. You You can’t necessarily give someone one training and then expect them to follow it if you never mention it again. Right. So this is an ongoing issue. It’s an ongoing topic. It’s a clinical topic. And it’s something that some people, some therapists really, really struggle with documentation. And so for different therapists, this is going to be something you’re talking to them about a lot. Others are going to be fine and it’s not going to be a big deal, right. So if for this therapist, this is this issue, just know if it’s probably going to be an ongoing issue. They’ll make improvements but it’s constantly going to be something that you will need to support them in. So adjust those expectations based on that person’s strengths and weaknesses and what policies you’re you know you have and plenty of people are able to catch up, able to manage it, but they’re, they’re going to need that push, and they’re going to need support from you. So make sure that, you know, you’re kind of altering those expectations and being realistic about people. And just knowing like, so for some of you might be in the position you’re in, because a lot of this stuff wasn’t an issue for you. So I understand that some of you, you totally get it, and you’re like, oh, yeah, I, you know, I always hated paperwork, it was always a struggle for me. And others of you are like, this was the easy part for me. So know that it’s very common, very, very common. And so it’s okay to understand that this is not a strength for everybody. That’s something you can open with.

Now, mistake, number three is “thinking they’ll never be good at notes so I have to micromanage that.”

So kind of on the flip side of that, of like, just not checking it at all, expecting to do one training and have them handle it perfectly after that, is really kind of like obsessively micromanaging people. I would say, you know, in this way, this is where it helps to have those really clear guidelines on what needs to be in a note so that you know, whether it’s a good note or not, to know when notes are due, because those are very clear boundaries. So if someone is not including the information in notes that you expect to have in notes, if they’re not doing them within the timeframe, then yes, that’s when you do things like performance improvement plans, or, you know, have conversations with people, whatever, potentially even let people go, right. But it doesn’t necessarily mean you need to micromanage them.

So, a lot of therapists are pretty good at this. And I’ve seen a lot of therapists who aren’t good in the beginning, then become good at this. But the thing is, so few therapists got any training. So maybe you give them this training, and you help them out a little bit. And then they’re like, oh, okay, now I get it. So kind of assume that they’re coming in blind. So it may not be an issue that’s going to be with this person all the time.

Mistake number four, is thinking “this is how I learned and how I do things. So that should work for them too.”

Documentation is very much like a time management thing. And obviously, this is going to depend a little bit on how your policies and procedures, work, how your practice works, all of that. But one of the most important things I think you can do is really talk to the clinician and figure out what the problem is. And one of the things I recommend–I have this, this framework that I work from to identify like, what are the common problems or common reasons people are having problems with documentation. So it’s usually I have this somewhere else in the presentation, but I’m gonna go through it now.

The first one is it’s–I call it QUOTE, right, because we have to have a fun acronym. So QUOTE.

And so the first would be QU questioning. So people are kind of questioning themselves and have a lack of understanding. So they’re just constantly questioning what should be in a note. O would be for others, they’re just constantly sitting there worried that other people are going to read their notes. So they’re constantly thinking about, like the liability aspect of it. Usually T is time. So it’s not necessarily a note writing issue, but it’s a time management issue. They have poor time management, and so you’re gonna need more direction that way. And then the last one, E is emotions. And this one is very commonly overlooked, where a lot of therapists take a long time writing notes or doing notes, not because it’s a time management issue, but because they are sitting there processing the session, or they’re bringing up other things for them. That happened, right. So for a lot of people, they use their notes as kind of that like almost clinical conceptualization time, or time to kind of like process their own emotions around things.

So depending on which of those issues is causing a problem for someone, you’re going to do different things. So it’s really important to kind of talk to them and figure that out. Is it that you’re sitting there and you’re just obsessing over what word to use? And that’s why it takes you half an hour to write a note? Or is it that you’re sitting there and really thinking through the case and feeling a lot of your own emotions? Are you avoiding notes because of lack poor time management? Or are you avoiding notes because this is a client that’s been very difficult for you to work with, and you’re kind of avoiding the emotions around dealing with that client.

Maureen Werrbach

Okay, so Maelisa goes over a handful of tips that relate to things that group practice owners might think that are actually either not true or unhealthy. And I really love the things that she brings up in this part of the training because I’ve seen myself and have also had to work on this myself as a group owner of really ensuring that our supervisors truly are trained in supporting the clinical staff when it comes to documentation.

And as you know, one of the biggest areas of pain for leadership in group practice is having people do notes on time, complete notes in an appropriate way. And there’s almost this expectation that once we’re fully licensed, we just know how to document well. And it’s so untrue. And like Maelisa mentioned, so many of us aren’t actually trained, appropriately and thoroughly enough on how to document appropriately. And so it’s really important as group practice owners that we focus on making sure that we have a process in place a training in place, where we can just make sure that new staff and established staff alike have a way to know that they’re doing their notes right.

And beyond just training, having supervisors who no one are setting up a regularly set schedule to look at their whoever they’re supervising notes, whether that person’s provisionally licensed or fully licensed, just so that they’re catching things, and also being able to allow for some creative freedom, right? Because Another thing I see is like these templates, note templates, where everything looks identical. And there’s people that just do notes in different sort of ways. And it’s not about having it be completely your way. But knowing what core things need to be in a note, and ensuring that your staff has this creative freedom to documenting in a way that resonates with them, but also accurately covers all the things that it needs to cover to be a good note.

And so my kind of last thoughts is if you’re a group practice owner who has a leadership team, to ask yourself, does your leadership team have any sort of feedback on how to appropriately assess their staffs notes in a way that they feel confident that they’re assessing well?

And if not, how can you set up a process where you can support them so that your supervisors feel like they truly know how to assess their team’s notes? And if you’re needing extra feedback, Maelisa at QA Prep dot com supports group practice owners in this and can help you put a system together that ensures that your clinical staff your leadership, is appropriately assessing their clinicians, notes and documentation as well as supporting them in making sure that your team knows how to effectively and accurately write notes. This training was really good and super thorough. So if you haven’t done a documentation training before, you should totally come in and take a listen to that because there’s going to be some great pieces of information in there that are going to be helpful for you as a business owner, and also for your team. I’ll see you next week.

Thanks For Listening

Thanks for listening to the group practice exchange podcast. Like what you heard? Give us five stars on whatever platform you’re listening from. Need extra suppor? Join The Exchange, a membership community just for group practice owners with monthly office hours, live webinars, and a library of trainings ready for you to dive into visit www dot members dot the group practice exchange dot com forward slash exchange. See you next week.


Here are the resources and guides we recommend based on this episode

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* I am an affiliate for some of the businesses I recommend. These are companies that I use in my own group practice, and make recommendations based off of my experience with them. When you use some of these companies through my links, I receive compensation, which helps me continue to offer great free information on my podcast, blog, Facebook group, and website.

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Meet your host


Maureen Werrbach is a psychotherapist, group practice owner and group practice coach. Learn more about her coaching services here:


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