This course will knock your socks off!!! The class provides clinical documentation protocol to meet utilization review, and evidence-based practice standards; covers documentation from assessment to discharge.

Developed by: Karen Albig Smith, LMFT, LCAS, MAC, CAP, SAP, SAE

Revised 2024


Description:   Clinical documentation of services provided to consumers of mental health services is a critical skill for mental health providers.  In today’s practice environment most providers are expected to apply evidence-based best practices. Clinical documentation must not only meet utilization review criteria but they must also substantiate model fidelity.  Assessments need to meet medical necessity standards.  Treatment plans need to utilize assessment information, describe consumer problems in behavioral terms, specify in measurable steps the objectives that have been individually selected to help consumers reach identified goals.  The study equips providers to be familiar with the language of case documentation including involvement of the consumer in the planning process.  Instruction includes an overview of assessment information used to develop treatment plans, writing an integrated summary, interdisciplinary treatment planning, developing and writing problem statements, goal statements, determining objectives, interventions and progress notation.  This course is a must for anyone who needs to learn how to better articulate treatment services.  Risk management concerns and legal issues are also discussed.

1.   Learners will be able to articulate five evidence-based documentation models.
2.   Learners will be able to describe comprehensive interdisciplinary assessment.
3.   Learners will be able to develop problems and need lists from assessment findings.
4.   Learners will be able to develop individualized treatment plans.
5.   Learners will be able to tie treatment activities to treatment plans.
6.   Learners will be able to connect documentation to review standards and ethical conduct.
Learning Assessment:
1.   Participants will be able to describe five evidence-based best practice models.
2.   Participants will be able to identify the four components of a comprehensive interdisciplinary assessment.
3.   Participants will be able to develop a master problem list from an interdisciplinary assessment summary.
4.   Participants will be able to formulate individualized problem statements from a master problem list.
5.   Participants will be able to write treatment goals in behavioral terms.
6.   Participants will be able to identify long-term goals and short-term measurable objectives from problem statements.
7.   Participants will be able to identify objectives, interventions, and deadlines for short-term objectives.
8.   Participants will able to differentiate the progress notation types.
9.   Participants will be able to discuss HIPAA as it affects clinical documentation.
10.  Participants will be able to describe the importance of informed consent.
11.  Participants will be able to articulate the special concerns when working with student providers.

CE Credits: 6

Hour One:   Introduction; Evidence-based practices.
Hour Two:   Interdisciplinary assessment, master problem lists, problem statements.
Hour Three:  Goal statements, objectives and interventions.
Hour Four:  Progress notation.
Hour Five:  HIPAA, Informed consent, Working with students.
Hour Six:     Posttest and course evaluation.

CE Broker#:  20-318285

Methods: Pre-test, study guide, posttest and evaluation, internet sources via URLs, Q&A by email.

Content Area: Documentation, Clinical evaluation, and assessment, Applications to practice, Risk management, Legal and regulatory, Professional orientation/readiness.

Purpose: At the completion of this course, providers should be better equipped to document comprehensive assessment, interdisciplinary treatment planning, and progress notation.

Target Audience:  Social workers, marriage and family therapists, licensed professional counselors, mental health counselors, nurses, employee assistance professionals, addiction professionals, behavioral health technicians, and other allied professionals who may work with these populations.

View a list of our approvals on our approvals page

Online Course

CE Broker#:
CE Credits:

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