Guidelines for Documentation

Guidelines for Documentation 

While providing direct service may be the core responsibility of your job, effective documentation tracks and details the needs, services, goals, and progress of the person served. The quality of your documentation also impacts decisions that are made about the services the person is receiving, ensures that all members of the care team communicate important details about those services, and ultimately, affects that person’s quality of life. This course will teach you the significance of documentation in your work with individuals. You will explore the importance of timeliness and accuracy in documentation and learn what to include to produce meaningful documentation. The learning experiences will include interactive activities to enhance your understanding of the material.


Hours: 1.25


Certificates provided by accrediting body (0 Match)

Course Details

Course Code: REL-HHS-0-GDOC
Hours: 1.25
Type: Online Course
Content Expiration Date: 9/30/2022
Learning Objectives:
Explain the importance of documentation.
Describe how to document accurately, concisely, and objectively.
Identify the most important elements to include to produce meaningful documentation.

Section 1: Introduction
A. About This Course
B. Learning Objectives
Section 2: The Basics of Good Documentation
A. Meet Gretchen
B. Why is Documentation Important?
C. Does Pen Color Matter?
D. Electronic Health Records
E. What Information Should be Handwritten?
F. Review
G. Summary
Section 3: The Importance of Timeliness
A. One Week Ago
B. Why is Timely Documentation Important?
C. Know Your Documentation Expectations
D. Overcoming Barriers to Timely Documentation
E. Review
F. Summary
Section 4: Improving the Accuracy and Objectivity of Documentation
A. Emphasize Objective Versus Subjective Information
B. Abbreviations
C. Accuracy and Electronic Medical Records
D. Helpful Do’s and Don’ts
E. Review
F. Summary
Section 5: Writing Meaningful Documentation
A. Documenting Goals and Progress
B. Documenting the Provision of Services
C. Documenting to Support Needed Services
D. The Cardinal Rule of Documentation
E. Let’s Review: Meet Marcelle
F. Summary
Section 6: Conclusion
A. Summary
B. Course Contributors
C. References
D. Congratulations

Expert Reviewer: Kristen Fuchs MA, LPC, CRC
Kristen achieved a Masters in Rehabilitation Counseling from The George Washington University. Kristen has experience working with individuals diagnosed with Schizophrenia in settings including Vocational Rehabilitation, Assisted Living Facilities, and Community Support Services. Disclosure: Kristen Fuchs MA, LPC, CRC has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Staff Writer: Monique Kahn, Psy.D.
Monique Kahn, Psy.D. received her doctoral degree in Clinical Psychology from Nova Southeastern University in Florida. She completed a pre-doctoral internship at Spokane Mental Health in Washington, which included specialty rotations in behavioral medicine and time-limited psychotherapies. She is licensed as a psychologist in Maine, where she was in private practice for 14 years, providing services to adult clients with varied presenting issues, but with particular emphasis on the treatment of anxiety disorders, the relationship between psychosocial stress and illness, insomnia, and coping with chronic illness. She has taught in the undergraduate psychology program at Husson University in Maine. In addition, she has worked as a content writer and psychology subject matter expert for several major educational publishing firms. She joined Relias as a clinical content writer and subject matter expert in 2016. Disclosure: Monique Kahn, Psy.D. 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, Intermediate level General Staff; in the following settings: Health and Human Services.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form ( or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.