Writing Progress Notes 101

 

Progress notes are the warehouses of medical facts and clinical thinking. A progress note is a succinct means of communicating about an individual’s present state. For this reason, the more proficient you are at writing progress notes, the more efficient you will become at communicating current findings. This course, tailored for all healthcare staff who access personal health records, discusses what an intelligent progress note consists of, the most common methods of writing them, and some useful tips for constructing them. Interactive exercises and illustrative vignettes will give you the chance to apply your new found writing skills. In addition, clinical practices, billing, and reimbursement guidelines vary widely for different agencies; as such, you must become familiar with your own policies and procedures as you apply these skills in your own agency. After completing this course, you will be able to write thorough, efficient progress notes for various clinical settings.

$25.00

Hours: 1.50
REL-HHS-0-WPN101

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Course Details

Course Code: REL-HHS-0-WPN101
Hours: 1.5
Type: Online Course
Content Expiration Date: 2/28/2022
Learning Objectives:
Articulate common guidelines for progress note writing.
Formulate progress notes that clearly document encounters, demonstrate medical necessity, and can be upheld by state/county audits.
Utilize the most common formats for developing progress notes in fifteen minutes or less.

Outline:
Section 1: Introduction
A. About This Course
B. Learning Objectives

Section 2: All about Progress Notes
A. Meet Larry
B. Why Are Progress Notes Important?
C. Proper Documentation
D. The Intelligent Progress Note
E. Noisy Notes
F. Compliance Rules
G. Remember Larry and Laura?
H. Review
I. Summary

Section 3: Methods of Progress Note Writing
A. Variety
B. The SOAP Note
C. Subjective
D. Objective
E. Assessment
F. Plan
G. The IGBIRP Method
H. Introduction (I)
I. Goal/Objective (G)
J. Behavior (B)
K. Interventions (I)
L. Response (R)
M. Plan (P)
N. The D.A.P. Progress Note
O. Data
P. Assessment
Q. Plan
R. General D.A.P. Note Considerations
S. More about General D.A.P. Note Considerations
T. Review
U. Summary

Section 4: Visualizing the Process
A. Meet Sarah
B. Basic Clinical Loop
C. Selecting Objectives
D. Selecting Interventions
E. Review
F. Summary

Section 5: Useful Tips for Charting
A. Preparation Is Important!
B. More Preparatory Guidelines
C. Useful Questions to Ask Before Charting
D. Progress Note Billing
E. Review
F. Summary

Section 6: Conclusion
A. Summary
B. Congratulations
C. Course Contributor
D. Resources
E. References

Staff Writer: Naju Madra, M.A.

Naju Madra, M.A. is an internal subject matter expert and clinical content writer for Relias' Behavioral Healthcare library. She earned her Master's degree in Psychology with specific study in neuropsychological assessment for children with Fetal Alcohol Spectrum Disorders. She brings with her a wealth of experience in clinical assessment, along with expertise in large-scale clinical research project management, recruitment, training, as well as in-person and web-based curriculum development.

In addition to scholarly activities such as writing manuals and preparing manuscripts for peer-reviewed journals, Ms. Madra has over 15 years of behavioral healthcare experience ranging from crisis counseling and job coaching for individuals with severe mental illness and co-occurring disorders, to community college instruction, and trauma specialist at the Veterans Health Administration. In her current role, Ms. Madra has contributed authorship to over 100 behavioral healthcare course offerings for both licensed and non-licensed professionals in the Health & Human Services market.

 Disclosure: Naju Madra, M.A. has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: entry level General Staff; in the following settings: Health and Human Services.
Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at [email protected]
Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.
Accommodations
If you require special accommodations to complete this module, please contact Relias Customer Support by calling (800) 381-2321 or emailing [email protected]