Presented by Sandy Morgenthal, M.Ed., PCC-S, CCFC
Friday, January 10, 2020
Documentation is required of all clinicians; a task that must be done. Knowing the requirements and learning a meaningful approach to the work of creating and maintaining client records doesn’t have to be as daunting as it sounds. If one’s attitude toward mathematics is, “I can’t do it!” then it can’t be done. The same is true of documentation. If it is approached from an “I Can!” attitude, then it becomes less of a burden to the clinician. Like many things, it is a question of habit and finding what works for the individual. It also requires meaningful tools. The instruments provided in Appendices A through E may be of some help.
Also important is the understanding and acceptance of the concepts of why we document. The protection of the client, the continuity of their care, and the ability to focus the sessions based on information previously gathered are the primary reasons keeping records is so essential. The protection and accountability of the therapist, and other reasons given herein are also helpful in motivating the clinician to get charting done.
Each professional must address time management issues and find ways to achieve required levels of recording client data in a timely manner. The most efficient and thorough approach will undoubtedly look different between therapists but must meet professional requirements and guidelines and standard of care expectations.
- Recognize the importance of professional documentation
- Understand the purposes of accurate record keeping
- Be familiar with some practical approaches to documentation
- Learn about computer-based documentation risks
Presenter: Sandy Morgenthal, PCC-S, CCFC, RN
Sandy Morgenthal is a licensed professional clinical counselor, supervisor, (LPCC-S) a clinically certified forensic counselor, (CCFC) and a registered nurse. (RN) She is a graduate of the University of Cincinnati with a bachelor’s degree in nursing, (BSN) and of Xavier University with a master’s degree in community counseling. (M. Ed.) She has taught on a variety of topics relevant to the practice of counseling, social work, and marriage and family therapy. She has provided this educational service on local, state, and national levels.
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