Description:  

Clinical documentation of services prvoded to consumers of mental health services is a critical skill for mental health providers.  In todays practice environment most providers are expected to apply evidence-based best practices. Clinicala documentation must not only meet utilization review criteria but they must also substantiate model fidelity.  Assessments need to meet medical necessity standards.  Treatment plans need to utilize assessment information, describe consumer problems in behavioral terms, specify in measurable steps the objectives that have been individually selected to help consumers reach identified goals.  The study equips providers to be familiar with the language of case documentation including involvement of the consumer in the planning process.  Instruction includes an overview of assessment information used to develop treatment plans, writing an integrated summary, interdisciplinary treatment planning, developing and writing problem statements, goal statements, determining objectives, interventions and progress notation.  This course is a must for anyone who needs to learn how to better articulate treatment services.  Risk management concerns and legal issues are also discussed.

Objectives: 

1. Participants will be able to describe five evidence based best practice models.

2. Participants will be able to identify the four components of a comprehensive interdisciplinary assessment. 

3. Participants will be able to develop a master problem list from an interdisciplinary assessment summary.

4. Participants will be able to formulate individualized problem statements from a master problem list.

5. Participants will be able to write treatment goals in behavioral terms.

6. Participants will be able to identify long-term goals and short-term measurable objectives from problem statements.

7. Participants will be able to identify objectives, interventions, and deadlines for short-term objectives.

8. Participants will able to differentiate the progress notation types

9. Participants will be able to discuss HIPAA as it affects clinical documentation.

10. Participants will be able to describe the importance of informed consent.

11. Participants will be abie to articulate the special concerns when working with student providers.

Agenda:

Hour One: Introduction; Evidence-based practices.

Hour Two: Interdisciplinary assessment, master problem lists, problem statements.

Hour Three: Goal statements, objectives and interventions.

Hour Four: Progress notation.

Hour Five: HIPAA, Informed consent, Working with Students.

Hour Six: Post Test and Course Evaluation.

Total CE Credits: 6

CE Broker#: 10-1217840         

Purpose: This class is intended to discuss the elements required to formulate and complete all types of clinical documentation as it pertains to the provision of mental health and substance abuse services.  At the completion of this offering, providers should be better equipped to complete comprehensive assessment, interdisciplinary treatment planning, and progress notation.