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About Beyond Therapy: The Basics of Clinical Documentation
Throughout the course of their training, behavioral health providers learn to be clinicians, to engage clients, understand the theoretical basis for treatment, develop an understanding of mental illnesses, and become advocates for their clients' well-being. Unfortunately, most clinicians are poorly trained in the administrative and regulatory aspects that impact their work, a significant aspect of which is documentation. Documentation, the primary focus of clinical chart audits, is scrutinized by regulatory bodies. Among other things, chart audits assess for medical necessity to determine whether or not the treatment is necessary and/or effective. Documentation that does not support medically necessary treatment potentially results in a recoupment of disbursements and, in extreme cases, a loss of clinical licensure. Whether in an agency or private practice setting, all practicing behavioral health providers are required to meet regulatory standards of practice, and under healthcare reform, these standards are increasingly stringent. To meet the demands of these standards, clinicians must have a working knowledge of the process and an understating of the standards and requirements to which they are expected to adhere. Emphasis will be placed on learning medical necessity terminology and developing functional skills in clinical documentation.
Detailed Information
| Author: | NetCE & Lisa Kathryn Jackson [NetCE & Jackson, Lisa Kathryn] |
|---|---|
| Publication Year: | 2020 |
| Language: | other |
| File Size: | 0.0679 |
| Format: | |
| Price: | FREE |
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