Course Code: REL-BHC-0-EDPN
Hours: 1
Type: Online Course
Content Expiration Date: 12/31/2028
Learning Objectives:
Indicate why documentation is critical and who relies on clinical records.
Identify effective documentation strategies.
Recall common documentation formats and when to use each one.
Outline:
Section 1: The Importance of Documentation
Documentation
How Documentation Supports Care
Types of Clinical Documentation in Behavioral Healthcare
Documentation of Marcus’s Care
Review
Key Takeaways
Section 2: Effective Documentation
Compliance, Accuracy, and Quality
Avoiding Fraud
Common Errors in Documentation
Quality Documentation
Documentation Considerations
Client-Centered Goal Setting
Demonstrating Medical Necessity
Implicit Bias in Documentation
Review
Key Takeaways
Section 3: Common Documentation Formats
Documentation Methods
The SOAP Note
The IGBIRP Note
The DAP Note
Approaches to Documentation
Golden Thread Approach
Collaborative Documentation
Review
Key Takeaways
Section 4: Conclusion
Course Summary
Course Contributor
Resources
ReferencesSubject Matter Expert: Amanda Gayle, Ph.D
Amanda Gayle received her PhD. in Counseling Psychology from the University of Tennessee. She completed a pre-doctoral internship at the University of Georgia in the Counseling and Testing Center. She also completed a post-doctoral fellowship at Duke University Medical Center in the Occupational Health Department working in both the internal and external employee assistance programs. She is licensed in North Carolina, where she was in private practice for 15 years, serving primarily adults in individual and couples counseling with many presenting issues. Her focus was on cognitive behavioral therapy to treat anxiety, mood disorders, grief, relationship difficulties, stress management, self-esteem, and parenting. She joined Relias as a subject matter expert writer for behavioral health in 2021.
Target Audience:
The target audience for this course is: Direct Care Staff; Unlicensed Personnel; in the following settings: Behavioral Health and Intellectual Developmental Disability, Behavioral Health: Community Services, Behavioral Health: Crisis Services, Behavioral Health: Intensive Services (IRTS), Behavioral Health: Outpatient Services, Behavioral Health: Residential Services, Behavioral Health: Social Rehabilitation Facilities, Behavioral Health: Substance Use Services, Behavioral Health: Substance Use Services: In-Home.
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 support@reliaslearning.com.
Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.