HS 219 Client Records, Case Management, and Care Coordination

1. Explain accepted principles of client record management including the importance of protecting client confidentiality. 
2. Identify and track the essential components of client records, including release of information forms, assessments, service (treatment) plans, individual service notes, transition and discharge summaries. 
3. Identify current Federal, State, local, and program regulations related to client documents. 
4. Employ the basic rules of correct grammar in preparing clinical documentation. 
5. Compose clear, legible, and concise records that comply with agency standards and relevant administrative rules. 
6. Synthesize and summarize client information in writing using electronic medical records system, and utilizing clinical terminology. 
7. Recognize and apply medical and behavioral health approaches.  
8. Identify and discuss case management and care coordination processes, and service support activities. 
9. Correctly complete release of information forms. 
10. Apply infectious disease regulations with respect to client confidentiality. 
11. Identify and discuss case management and care coordination processes and service support activities. 

• Introduction and Overview 
• Confidentiality 
• Administrative Rules and Regulations 
• Developing the Assessment 
• Service and Support Planning 
• Writing Service and Support Notes 
• Writing Service Conclusion Summaries and Reports 
• Forms and Other Documentation 
• Client Service Record as a Tool for Case Management, Care Coordination, Organization, and Time Management