Documentation And Record Keeping: Essentials for Social Works Administrators

This training program explains the goals and potential benefits of effective clinical documentation as well as the ethical and legal requirements for doing so. Documentation is addressed from a clinical and risk management perspective. Specific recommendations are made for how to document the clinical services provided in a competent and effective manner. Additionally, common pitfalls to avoid are addressed. How to store and maintain records is addressed for both paper and electronic records. Precautions to take to protect and preserve records are described in detail along with how and when to dispose of them. Guidance is provided for following HIPAA and other laws and regulations relevant to documentation and record keeping. Participants in this webinar will receive practical guidance that can be integrated into daily practice to document more effectively, to better achieve the goals of thoughtfully created treatment records, and to meet and exceed professional standards and practice guidelines relevant to documentation and record keeping.

OBJECTIVES

At the end of this seminar, participants will be able to:

• Explain the goals of documentation
• Describe the elements of effective documentation
• Explain how effective documentation is a risk management strategy
• List steps to take to protect electronic health records
• Name three things to avoid in your documentation

CONTENT

• Goals of documentation
• Essentials element of documentation
• Advantages of effective documentation
• Risks of poor documentation
• Case law
• Examples
• HIPPA
• Informed consent
• Risk management strategies
• Electronic records
• Key recommendations

FOR WHOM

Psychologists, Social Workers, Counselors, Therapists, Psychiatrists and Nurses

TRAINING METHODOLOGY

The training methodology combines lectures, discussions, group exercises and illustrations. Participants will gain both theoretical and practical knowledge of the topics. The emphasis is on the practical application of the topics and as a result participant will go back to the workplace with both the ability and the confidence to apply the techniques learned to their duties.