Documentation in health care is one of the “necessary evils” of the profession – we cannot get paid or justify our treatment plans unless services are documented. Given the time demands in clinical work, however, charting can often be very brief and may not consider all the audiences that might access the medical record. Further, we may not have had guidance in our practical training experiences about how to chart in a concise, yet complete and ethically-sound manner. This presentation will help you “chart like a champ,” understanding key principles and components of excellent documentation.

After attending this presentation, you will be able to:

1) Explain the rationale and ethics of good documentation and the general principles of defensible and useful charting; and,
2) Demonstrate clarity with regard to specific components of documentation to meet Medicaid guidelines and incorporate multiple ‘audiences’ and specific populations when charting.

*Submission of the conference evaluation form indicates your completion of the entire program.

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