Training Title:
Clinical Documentation: Improving Your Clinical Documentation

Clock Hours: 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