When available, the Online Course format is included with the hard copy, eBook, or audio book formats!
For social workers, counselors, and psychologists, documentation is equally important before, during, and after a clinical encounter. Although therapists often view documentation as an unwelcomed task and least favored activity, it serves multiple essential purposes. However, it is fraught with risk and liability.
This intermediate-level course is intended for both beginning and seasoned practitioners. After examining the clinical, administrative, and legal rationales for documentation, the course describes the content of good clinical documentation, discusses a chart’s organization, and presents the different styles of progress notes. The course analyses the ethical issues commonly encountered by therapists when documenting, including information related to the storage, release and disposal of records; service reimbursement or extension; documentary evidence; group notes; client access to records; documenting in a digital world; publication; and, supervision.
Case vignettes throughout the course highlight risk management techniques as they relate to documentation, particularly in the case of subpoenas or other litigious situations. Therapists usually know what is minimally required in documentation; however, what is minimally required may differ significantly from what is recommended or optimal. Optimal documentation includes information that is relevant to the clinical services being provided and that addresses legal, ethical, and administrative obligations. This course will help practitioners approach documentation in a way that is guided not solely by what is mandated, but by what is mutually beneficial to all stakeholders in the documentation process: the practitioner, the agency, the funding source, and most of all, the clients. This course illuminates the complex nuances of writing for the clinical record and provides information to assist the practitioner in determining when, what, and how much to document. In addition, summaries related to documentation from the codes of ethics of the American Association of Marriage and Family Therapy (AAMFT), the American Counseling Association (ACA), the American Psychological Association (APA), and National Association of Social Workers (NASW) are included in the appendix – to aid therapists in gaining increased confidence and skill in writing sound clinical and ethical documentation.
3 NBCC hours will be awarded upon completion of this course.
Social Workers will receive 3 (Ethics) continuing education clock hours upon successfully completing this course. Accreditations
- Explain the rationale for high-quality documentation.
- Describe the content of good clinical documentation.
- Identify aspects of clinical documentation that present potential ethical problems.
- Describe decision making in ethical documentation.
Claudia J. Dewane, DEd, LCSW, BCD, is an associate professor in the College of Health Professions and Social Work at Temple University in Philadelphia. She received a doctorate in adult education and health psychology from Pennsylvania State University and an MSW from Columbia University. Dr. Dewane is a licensed clinical social worker, maintains board-certified diplomate status in clinical social work, and has a certificate in advanced clinical supervision. She is the founder of Clinical Support Associates, a private firm providing supervision, consultation, and training to professional social workers. She has presented numerous workshops on clinical, supervisory, and ethical issues in social work. Dr. Dewane has also taught and published on ethics and supervision.
- Contact hours will be awarded for up to one (1) year from the date the course is ordered.
- You must score 75% or higher on the final exam and complete the course evaluation to pass this course and receive a certificate of completion.
- Through our review processes, Western Schools ensures that this course content is presented in a balanced, unbiased manner and is free from commercial influence. It is Western Schools’ policy not to accept commercial support.
- All persons involved in the planning and development of this course have disclosed no relevant financial relationships or other conflicts of interest related to the course content.