Basics of Effective 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.
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.
National Academy of Certified Care Managers
Relias,LLC is approved by the National Academy of Certified Care Managers (NACCM) as a continuing education provider, #18-502RA.
This activity approved for 1.00 CMC contact hours
National Alliance for Direct Support Professionals
This activity is approved for 1.00 contact hours.
Recall why effective documentation is critical and the key elements you should include in your documentation
Indicate at least three strategies you can use to improve the quality of your documentation.
Outline:
Section 2: The Importance of Documentation
Why is Documentation Important?
Section 3: Elements of Effective Documentation
What Makes Documentation Effective?
Section 4: Strategies to Improve Documentation
Strategies for Timely Documentation
Documenting Provision of Services
Writing Tips for Provision of Services
Section 5: Documentation Methods
Find a Method That Works for You
Instructor: Jacob Helton, Psy.D.
Jacob Helton, Psy.D., received his doctoral degree in Clinical Psychology from Marywood University in Pennsylvania. He completed his pre-doctoral internship at Chehalem Youth and Family Services in Newberg, Oregon, which included extensive training with at-risk youth and their families. He is licensed as a psychologist in Oregon and most recently worked in an integrated family medicine and internal medicine group for a large healthcare organization. Dr. Helton has worked in hospital, school, residential, and community mental health settings. He has provided treatment to clients across the lifespan and diagnostic spectrum, with an emphasis on the treatment of anxiety disorders, co-occurring medical and mental health disorders, ADHD, insomnia, severe and persistent mental illness, and the aging. He has experience as a technical writer and has provided numerous trainings to mental health professionals, physicians, allied professionals, and direct care staff.
The target audience for this course is: Direct Care Workers.
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 (https://www.relias.com/help) 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.
