ABOUT THIS COURSE:
A vital element in providing and documenting clinical care, an accurate, thorough clinical record is also important as a risk-management tool for protecting consumers and practitioners in the event of an ethics claim or lawsuit. The clinical record provides a permanent account of not only the consumers needs, treatment, and progress, but also the practitioners treatment plan, including her/his rationale for treatment decisions. Unfortunately, record-keeping is often given a low priority, which results in records that are poorly maintained and are not readily available when needed. In this course, you will learn why keeping accurate medical records is such an important aspect of providing clinical care, along with techniques for ensuring that your documentation gives a clear picture of the care and treatment of the consumers with whom you work. This course will teach you the essential elements of good charting, including what belongs in the clinical record - and what does not - along with how to apply best practices in documenting consumer care. This training will teach you how to maintain clinical records that not only meet the minimum documentation standards set by accrediting agencies such as The Joint Commission, but also facilitate the clear, consistent communication that is so essential for providing consumers care of the highest quality. This course, which is appropriate for caregivers in a variety of roles in diverse health and human services settings, gives you an opportunity to apply your new knowledge using interactive exercises and vignettes to reinforce your learning.