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Documentation 101 – An Overview

From the video: Documentation is critical to the success of clinical care. It’s critical to the success of getting paid for what you’re good at and what you do and it’s critical for historical purposes so that you can identify where you started and where you’re going. It’s also helpful in setting some goals and expectations with you and the patient or the group. You have to be able to translate what you actually did in a group or individual session or family session onto a piece of paper. So how do you do that? Well, the first thing is that you have to write what happened objectively – who showed up; what time they showed up; if you’re using names, their names; if you have an intervention, what intervention you used and then certainly a goal that you want to establish moving forward. But anything objective, you want to be able to utilize documentation so that if someone reading that note wasn’t in the group or the individual session or the family session they would actually know what went on objectively…For more, watch the video above!