CLINICAL DOCUMENTATION

Course Description:

This course provides learners with a proven format for properly documenting clinical sessions, and case management encounters.  This course will focus specifically on strategies and best practices for writing high quality encounter notes for most clinical processionals.

Course Objective:

At the end of this training, learners will be able:

• Describe the foundational steps to good documentation.
• Define an encounter note.
• Explain how encounter notes are used by persons in care, direct service staff, provider agencies, and the government entities.
• Write encounter notes that follow the “SIRP” structure.
• Demonstrate best practices and effective strategies for writing detailed encounter notes.

Intended Audience:

Direct Service Workers; quality assurance staff, clinical supervisors