Best Practices in Clinical Documentation
- Trainer: Nompelelo Boucher, PhD.
- Friday, Nov 13 · 9:00 AM – 11:00 AM ET
- Live online via Zoom
Course details: Best Practices in Clinical Documentation
Understand the ethical and multicultural issues associated with assessment, treatment and clinical documentation. To learn about the Five Steps to Competent Clinical Documentation such as case conceptualization. Conceptualize the presenting issue with the help of theory and client’s lived experience. To learn the importance of using assessment tools to understand the client’s mental status, risk assessment and symptom severity to support medical necessity. Take into consideration issues of social justice, multicultural experiences, as well as attention to issues of diversity, equity, and inclusion. In the treatment planning phase focus on measurable goals and assessing for other services needed to support treatment. Evaluating progress towards identified goals. This training will also focus on how to document crisis and risk management issues, supervision, case consultation, and collateral contacts. We will use case examples to discuss the tone of documentation such as writing in an objective, observational and dispassionate tone to decrease the use of personal judgement, biases, interpretations, and derogatory remarks.
Continuing education
- 2.0 CEUs (National Association of Social Workers – RI Chapter, RI Certification Board Chemical Dependency, and Licensed Mental Health Counselors through the RI Mental Health Counselors Association)
- 2.0 NBCC-approved continuing education credit hours
- Approved for 2.0 NAADAC CE Hours
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