CLINICAL DOCUMENTATION: Do's and Dont's

Course overview

Clinical records form a permanent account of clinical and client/patient considerations and the reasons for decisions. They are essential. This course reviews many necessary and essential aspects for clinical records with good practice points applicable in a variety of mental health and healthcare settings. Records should always reflect services, but a clinician's records also afford protection for the provider when the records are appropriately, ethically, and consistently managed and maintained. This presentation begins with introductory information on recordkeeping guidelines, and then quickly moves into important dos and don'ts, how much to document, and content guidelines and samples. There are many difficult situations that can arise in clinical settings, and knowing how to write notes ethically, appropriately, and accurately is essential. Sample wording for various challenging situations is included.