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Documentation Training

Training on Documentation

Tonya Pulliam

on 26 September 2012

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Transcript of Documentation Training

Enhancing Documentation Skills Rules of
the Form Importance of Documentation Appropriate
Terminology Pulliam Innovative Consulting Firm Conclusion is here is important too is important Tonya L. Pulliam, MSW Regulatory Agencies
DMAS--Medical Model
Licensing Agencies
Board of Licensure
Contracts Documenting
Behaviors Using Terms Inappropriately
Spell & Grammar Checks
Understanding Your Audience There should be a progress note documented following each session
Progress notes must be signed by the author, and have their credentials clearly documented.
Progress notes must contain the date of the session and the length of time of the session, with either a beginning and ending time or a total time spent with the consumer.
Progress notes can be written in several different formats, three discussed here are the SOAP, the DAP and BIRP. Documenting
Interventions B--Behaviors exhibited during session or prior to; behaviors discussed as a part of the treatment plan.
I--Interventions used during session, clinical skills, techniques, counselor driven
R--Response or lack thereof, by client to the intervention
P--Plan of action for next session or immediate needs
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