Documentation - TCM
Documentation in Target Case Management
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Start now!Language: English | Category: Mental Health
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What you will learn
Gain a comprehensive understanding of documentation requirements based on various funding sources
Learn about the legal and ethical considerations in case documentation
Develop skills in strength based and person centered writing techniques
Explore different types of case records and their specific uses
Receive an introduction to the fundamentals of effective case documentation
Engage in practice and peer review to enhance documentation skills
Learn how to document crises and incidents accurately and effectively
Gain an overview of different note formats and their applications
Understand how to link documentation to the service plan for cohesive care
Master the art of writing effective progress notes that reflect client progress
Course Content
Foundations of Documentation
Introduction to Case Documentation
The Role and Purpose of Documentation in Case ManagementThe Role and Purpose of Documentation in Case ManagementPractice now!
How Documentation Impacts Client Outcomes and Service DeliveryHow Documentation Impacts Client Outcomes and Service DeliveryPractice now!
Common Documentation Errors and How to Avoid ThemCommon Documentation Errors and How to Avoid ThemPractice now!
Legal and Ethical Considerations
HIPAA, 42 CFR Part 2, and Confidentiality StandardsHIPAA, 42 CFR Part 2, and Confidentiality Standards
Informed Consent and Client Rights in RecordkeepingInformed Consent and Client Rights in Recordkeeping
Mandated Reporting and Legal Risks in DocumentationMandated Reporting and Legal Risks in Documentation
Documentation Requirements by Funding Source
Medicaid Standards for Medical NecessityMedicaid Standards for Medical Necessity
Third-Party Payer and Audit ExpectationsThird-Party Payer and Audit Expectations
Documentation Do’s and Don’ts for Billing ComplianceDocumentation Do’s and Don’ts for Billing Compliance
Types of Case Records
Service Plans, Assessments, and Progress NotesService Plans, Assessments, and Progress Notes
Treatment Team Reports and Case PresentationsTreatment Team Reports and Case Presentations
Referrals, Releases, and Consent FormsReferrals, Releases, and Consent Forms
Strength-Based and Person-Centered Writing
Using Objective and Neutral LanguageUsing Objective and Neutral Language
Highlighting Client Strengths and PreferencesHighlighting Client Strengths and Preferences
Avoiding Stigmatizing or Biased TerminologyAvoiding Stigmatizing or Biased Terminology
Note Writing and Clinical Documentation Formats
Overview of Note Formats
SOAP Notes (Subjective, Objective, Assessment, Plan)SOAP Notes (Subjective, Objective, Assessment, Plan)
DAP Notes (Data, Assessment, Plan)DAP Notes (Data, Assessment, Plan)
AIRE Notes (Assessment, Intervention, Response, Evaluation)AIRE Notes (Assessment, Intervention, Response, Evaluation)
Writing Effective Progress Notes
What Makes a Progress Note Clinically Useful?What Makes a Progress Note Clinically Useful?
Capturing Client Interactions and Service DeliveryCapturing Client Interactions and Service Delivery
Real-Time vs. Retrospective Note ChallengesReal-Time vs. Retrospective Note Challenges
Linking Documentation to the Service Plan
Connecting Goals and Objectives to NotesConnecting Goals and Objectives to Notes
Tracking Progress and Barriers Over TimeTracking Progress and Barriers Over Time
Ensuring Services Match the Treatment PlanEnsuring Services Match the Treatment Plan
Crisis and Incident Documentation
Documenting Emergencies and Critical EventsDocumenting Emergencies and Critical Events
Writing Incident Reports with Clarity and PrecisionWriting Incident Reports with Clarity and Precision
Follow-Up and Recovery DocumentationFollow-Up and Recovery Documentation
Practice and Peer Review
Case Scenarios and Practice Note ExercisesCase Scenarios and Practice Note Exercises
Peer Review Techniques and Feedback ProtocolsPeer Review Techniques and Feedback Protocols
Improving Writing Skills Over TimeImproving Writing Skills Over Time
Effective Documentation Practices
Ensuring Documentation Accuracy
Internal Reviews and Supervisory AuditsInternal Reviews and Supervisory Audits
Creating and Using Documentation ChecklistsCreating and Using Documentation Checklists
Common Red Flags During Compliance ChecksCommon Red Flags During Compliance Checks
Optimizing Timeliness and Frequency
When to Document and Why Timing MattersWhen to Document and Why Timing Matters
Handling Late Entries and Addendums ProperlyHandling Late Entries and Addendums Properly
Setting Frequency Standards Based on Level of CareSetting Frequency Standards Based on Level of Care
Securing Digital Records
Using EHR Systems Securely and EffectivelyUsing EHR Systems Securely and Effectively
Implementing Passwords, Access Logs, and Role-Based SecurityImplementing Passwords, Access Logs, and Role-Based Security
Transitioning Between Paper and Electronic RecordsTransitioning Between Paper and Electronic Records
Efficient File Organization
Structuring Client Files for Accessibility and ReviewStructuring Client Files for Accessibility and Review
Understanding Record Retention Policies by State/AgencyUnderstanding Record Retention Policies by State/Agency
Managing File Transfers, Closures, and ArchivingManaging File Transfers, Closures, and Archiving
Preparing for Audits and Reviews
Understanding Auditors' ExpectationsUnderstanding Auditors' Expectations
Conducting Pre-Audit File Review and Corrective ActionsConducting Pre-Audit File Review and Corrective Actions
Implementing Documentation Training Plans in Response to Audit FindingsImplementing Documentation Training Plans in Response to Audit Findings
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