Training Title:
Clinical Documentation: Customer-Focused, Outcome-Driven, Recovery-Oriented and Strengths-Based - Part 1

Clock Hours: 1.5

Objectives:
At the completion of this course, participants will be able to: • Describe how the clinical documentation process could be used as part of the actual clinical process, as a teaching tool • Describe the negative effect of referring to documentation as “paperwork” • List and describe at least 4 purposes for clinical documentation • Describe the 6 components of a recovery-oriented assessment summary and plan • Describe the two key ingredients of an outcome-focused progress note • List the 7 essential clinical decision made through the clinical management

Description:
The goal of this course is to challenge your thinking about the clinical management process and documentation of that. Instead of seeing it as “paperwork”, a tedious requirement that keeps you from the real stuff of “helping people”, you can come to see it as a training tool for those with whom you work. The entire clinical record could be a medium through which you teach people how to problem solve, set goals, plan actions to achieve them, check on progress, make changes when needed and celebrate success. But, to do this, you will need to change your thinking about the record and, even parts of the clinical process. You will need to shift from the pathology process focus about people and treatment to an outcome-focused, person-centered, recovery-oriented and strengths-based perspective. Our goal is to start that thinking shift in this article. How do these concepts all relate? In effect, the driving position is one of being outcome-focused, that is, working toward the end results desired by the individual served. Focusing on the individual’s desired outcomes means almost by default that you are also being person-centered. It is the individual person’s outcomes you are working to achieve. When individuals with serious mental illnesses are asked how they want their lives different or better, they want what most of us want – more money, a decent job, a meaningful intimate relationship and decent housing. As noted previously, they want a “recovered life”, thus, the recovery-orientation. And, finally, identifying and building on existing strengths is a more efficient way to achieve desired outcomes Keywords: Clinical management process, documentation, paperwork, clinical record, medical record, chart, medical chart, outcome-focused, person-centered, recovery-oriented, strengths-based, recovery, assessment, treatment plan, recovery plan, medical necessity, progress, progress note, service plan, Skypek

Approval Bodies