BH 219 Client Records and Documentation Standards

Lecture Hours: 1
Credits: 1

Covers the preparation of clinical documentation related to screening and intake processes, assessments, treatment plans, reports, progress notes, discharge summaries, and other client-related data using current behavioral health terminology. Incorporates State, Federal, and other professionally relevant standards to client records.

Prerequisite: Admitted into Behavioral Health program; and completion of BH 150 and BH 170 , each with a grade of C or better; or consent of instructor.
Concurrent: Concurrent enrollment in BH 203.
Student Learning Outcomes:

Understand confidentiality rules as they apply to record management, including but not limited to correct use of releases of information documents as it relates to substance use disorders and infectious disease regulations
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.
Identify current Federal, State, local, and program regulations related to client documents.
Compose clear and concise records that comply with agency standards and relevant administrative rules.
Synthesize and summarize client information in writing using electronic medical records system and utilizing clinical terminology.

Content Outline

Introduction and Overview
Review Confidentiality, Administrative Rules and Regulations
Releases and Informed Consent
Assessment Tools
Service and Support Planning
Forms and Other Documentation
Writing Service and Support Notes
Writing Service Conclusion Summaries and Reports