Documentation: Assessment,Planning Treatment and Noting Progress

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.

CE Credits: 6 (NBCC Hours - 6)

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.