Documenting Care in Behavioral Health Settings

This program covers the following topics:

Purposes of the clinical record

Clinical record formats and styles

Health care trends affecting documentation

Do's and Don'ts of nursing documentation

 

LEARNER OBJECTIVES

 

Upon completing this self-study program you should be able to:

 

-Identify the critical purposes of the clinical record.

-Define the characteristics of a clinical record entry that create an effective and legal entry.

-Examine and compare different styles and models of clinical record entries.

-List trends in health care today that impact written communication in the clinical record.

-Explain how legal and reimbursement problems occur due to omitted, altered, incorrect or incomplete clinical record entries.

-List characteristics of documentation that increase both legal and reimbursement risk.

-Differentiate between chart entries that do and do not meet the criteria of an effective and legal entry.

Formats Available

Cost

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Self-study module - Ebook in PDF

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Printed self-study packet (for volume discounts contact NurseLearn at:

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$25

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