4. Documentation (CBHCM) Ver 11-2021

Content
9 modules
Rating
Instructor
e TRAINING

Description

Tasks in this domain are directly related to documenting service provision according to federal, state and agency requirements and best practices. Documentation competencies apply to all job tasks of a targeted case manager and must be demonstrated from case initiation through case termination/closure. Documentation is a practical as well as legal responsibility. The utmost care must be taken to professionally document all relevant aspects of care in a manner that provides clear, accurate and comprehensive information as the client record travels with them across providers. Effective documentation not only documents case management outcomes, it also can demonstrate compliance with person-centered, individualized planning. Documentation tasks are not sequential, CBHCMs use professional knowledge and skills to determine when and how to conduct job tasks.

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Objectives

Job Tasks

1. Use best practices for written documentation in order to record all relevant case management services activity and information in a clear, concise, observable/objective, professional and timely manner.

2. Protect the client’s right to privacy and confidentiality according to laws and other governing rules when preparing and handling records, especially regarding the communication of client information with third-parties.

3. Obtain written consent to release information from the client and/or legal guardian according to agency protocols and administrative rules.

4. Document process, progress and outcome measurements in accord with the client’s service plan, assuring a clear linkage between case documentation and the service plan.

5. Comply with legal, funder and agency requirements and timelines for documentation.

Certificate

By completing/passing this course, you will attain the certificate Documentation (10 hours)

1.
A. Assessment, Treatment, Progress, Discharge or Transfer Summaries 2 hrs
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2.
B. Clinical Documentation - 2 hrs
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3.
C. Electronic Health Records/Technology - 1 hr
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4.
D. Privacy & Confidentiality - 1 hr
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5.
E. Progress Notes - 1 hr
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6.
F. Psychosocial Summaries - 1 hr
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7.
G. Reports/Record Keeping/Records Management - 2 hrs
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8.
Case Management Forms and Exercises
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9.
Medicare & Medicaid Fraud and Abuse Mandatory Reporting
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