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 listening to this speaker, participants will leave able to:
1) Provide an inventory of the rationale and ethics of good documentation, along with the general principles of defensible and useful charting; and,
2) Show clarity with regard to specific components of documentation to meet Medicaid guidelines and incorporate multiple “audiences” and specific populations when charting.
