Safe and Practical Documentation (5 CE Hours)
- 1 Section
- 5 Lessons
- 2 Quizzes
Safe and Practical Documentation (5 CE Hours)
- Module 1: The Ethical and Legal Foundations of the Clinical Record
- Module 2: The Narrative Begins: Screening, Intake, and Assessment
- Module 3: The Golden Thread: Treatment Plans and Progress Notes
- Module 4: Transitions and Conclusions: Discharge and Transfer Summaries
- Module 5: Modern Record Management and Technology
- Post-Test: Safe and Practical Documentation
- Program Evaluation
This comprehensive 5-hour Continuing Education course is specifically designed for North Dakota Licensed Master Addiction Counselors (LMACs) and Licensed Clinical Addiction Counselors (LCACs). The curriculum addresses the critical intersection of clinical excellence and administrative compliance, adhering to TAP 21 competencies and NAADAC ethical standards. Participants will explore the full lifecycle of clinical documentation, from the initial biopsychosocial assessment to the discharge summary, with a specific focus on maintaining the "Golden Thread" of medical necessity. The course provides advanced training on managing Electronic Health Records (EHR), navigating the complexities of 42 CFR Part 2 and HIPAA privacy regulations, and implementing risk management strategies for record retention and disposal.
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