|
|
|
|
A Practical Approach To Documentation
Click here for the text
of A Practical Approach to Documentation (24 pages of
text) I: Why Should We Document? a. Protection of the Client b. Protection of the Worker c. Worker Accountability d. The Record Provides the Structure and Focus of Services e. Accurate Documentation Meets Individual, Agency and Other Payer Source Requirements f. Meets Quality Assurance Requirements and Outcome Measures II: What Should We Document? a. What Does an Accurate File Need to Include III: How Do We Document? a. Methods 1. The SOAP Method 2. The DAR Method 3. The PIE Method 4. The Dynamic Method 5. The Narrative Method 6. SMART Goals IV: Who Owns The Record? V: How Long Must The Records Be Maintained IV: Confidentiality IIV: Computer Charting Goal: Participants will learn how to create and maintain client records which meet patient care, quality assurance and ethical standards. Objectives: 1. Participants will learn the importance of accurate record keeping. 2. Participants will learn how to use multiple record keeping methods. 3. Participants will learn the risks of computer-based documentation. Methods: Written Test, Post Test, Resource List Author: Sandy Morgenthal, LPCC RN is in private counseling practice and is a registered nurse. She provides clinical supervision for Counselor Trainees and serves as adjunct faculty at the Xavier University Masters in Counseling Program and at Cincinnati Bible College and Seminary. She also provides professional presentations to local and state audiences. |
Send mail to webmaster@heiselandassoc.com with
questions or comments about this web site.
|
