Training Title:
Clinical Documentation: Customer-Focused, Outcome-Driven, Recovery-Oriented and Strengths-Based - Part 2

Clock Hours: 1.5

Objectives:
At the completion of this course, participants will be able to: • Describe the core components of the Massachusetts and New York clinical documentation processes • Describe how assessed needs such as symptoms, problem behaviors, and functional deficits are incorporated into Loveland and Boyle’s Recovery Model • Describe the benefits of concurrent or collaborative documentation • Describe the process for tracking assessed needs from the assessment, through planning, through progress evaluation and back again through updates

Description:
The goal of this course is to show you and evaluate with you one design for clinical documentation that is intended to meet the needs for documenting medical necessity for third party payers and ties those medically necessary conditions to recovery-oriented planning and outcome-focused progress evaluation. We will look at what is good about this design, implemented with some variations, in the states of New York and Massachusetts and presumably used by a significant number of provider organizations. And we will suggest some changes that might improve the design. 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