Documentation and Confidentiality (10 Contact Hours)
- 1 Section
- 12 Lessons
- 2 Quizzes
Documentation and Confidentiality (10 Contact Hours)
- Course Overview & Introduction
- Module 1: The Golden Rule of Record Management
- Module 2: Objective Versus Subjective Documentation
- Module 3: Writing Precise Shift Notes
- Module 4: Utilizing Structured Formats SOAP and DAP
- Module 5: Maintaining the Golden Thread of Care
- Module 6: Documenting Critical Incidents and Events
- Module 7: Foundations of Privacy and HIPAA Regulations
- Module 8: Navigating 42 CFR Part 2
- Module 9: Managing Consent and Information Releases
- Module 10: Electronic Health Record Security
- References & Policies
- Post-Test Documentation & Confidentiality
- Program Evaluation
This entry-level course provides behavioral health technicians with the essential skills to generate clear and legally defensible clinical documentation. Participants will master the fundamentals of objective reporting and navigate the critical importance of patient privacy in residential treatment settings. Completing this training equips support staff to produce accurate shift notes that protect the client and the agency.
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