Clinical Documentation: Improving Your Clinical Documentation
Category:
13
Credits:
2
Objectives:
At the completion of this program participants should be able to:
• Describe the content and process of completing a Bio-Psycho-Social, Mental Status, and Daily Functioning assessments.
• Identify the various components of a treatment plan.
• Recall at least five rules for making entries in a clinical record.
• Describe the importance and how progress notes tie into the treatment plan.
• Identify one format for documenting a service contact
• List five ways that you can check to make sure your records meet basic standards for clinical documentation.
Description:
This course provides a sound conceptual foundation of the basic clinical documentation process. Based on professional standards, legal requirements, and auditor’s perspectives, guides are presented for clinical documentation. Basic skills for assessment, treatment planning, clinical intervention documentation are taught.
Key Words:
clinical documentation, record keeping, Medicaid requirements, progress notes, service plan, treatment plan, clinical assessment, chart entries, medical necessity
Approval Bodies:
Florida Dept. of Health (Board of Social Work, Marriage & Family, Mental Health Counseling)
NAADAC, National Association for Addiction Professionals
National Board for Certified Counselors
Florida Board of Nursing
Association of Social Work Boards Approved Continuing Education (ACE)
California Consortium of Addiction Programs and Professionals (CCAPP)
CAADE - California Association for Alcohol/Drug Educators
Pennsylvania Certification Board
Florida Board of Psychology
California Board of Registered Nursing
California Association of DUI Treatment Programs (CADTP)
Ohio Chemical Dependency Professionals Board 2023
Ohio Chemical Dependency Professionals Board 2022
Illinois Alcohol & Other Drug Abuse Professional Certification Association, Inc. 07/20-22 (P)
Illinois Alcohol & Other Drug Abuse Professional Certification Association, Inc. 7/22-24 (CQ).
