Classroom Course » Clinical Documentation Basics (Developmental Services)

Designed for New Employees that are supporting individuals with IDD diagnoses.  The class is appropriate for IDD Managers, Supervisor, Support Coordinators, and Counselors only. The course will address the intake, assessments, the person centered individual service plan, person centered review, support log notes, and discharge.  The course addresses policies and regulations and provides technical instruction in ProFiler.

General Clinical Documentation Overview

-Agency Abbreviations

-Understanding Medicaid Abuse and Fraud

-Review of expectations of documentation practices

-Person Centered Language practices

-Facilitating an agency intake with Profiler demonstration and practice

-Review of CMS Final Rule

-Review of ISP (Parts 1-5) with Profiler demonstration, practice, and feedback on part 3 and part 5

-Completion of Person Centered Review with Profiler demonstration and practice

-Writing of support notes

-Documentation of Discharge Summary with Profiler demonstration and practice