Best Practices in Documentation

Course overview

This course reviews fundamental rules and regulations around documentation. Presenters review legal and ethical guidelines that shape documentation practices. This includes recommendations for approaching these topics in various situations. Topics like informed consent, managing confidentiality, and timeliness as it impacts a clinicians ability to document a diagnostic assessment, treatment plan, and session notes are discussed. Common strategies or recommendations for writing quality examples of these documents are also shared. Included are examples of documentation i.e. a sample diagnostic summary, treatment plan goals, and session notes are shared and reviewed. Links to resources such as the legal and ethical codes, that are referenced in this training are provided, as are those for many insurance manuals that shape documentation practices.