Ace the Addiction Counselor Exam With These Documentation Techniques

Documentation Techniques to Ace the Addiction Counselor Exam Dr. Dawn-Elise Snipes is a Licensed Professional Counselor and Qualified Clinical Supervisor. She received her PhD in Mental Health Counseling from the University of Florida in 2002. In addition to being a practicing clinician, she has provided training to counselors, social workers, nurses and case managers internationally since 2006 through AllCEUs.com Subscribe and click the bell to be notified of new episodes #ncmhce #addictioncounselor #examreview #documentation #cadc #NAADAC 00:00 Intr0duction 00:30 Objectives 01:00The client record is the most important tool to ensure continuity of care Documentation contributes to service delivery by: Reducing replication of services Presenting a cohesive longitudinal record of clinically meaningful information Ensuring reimbursement for services 05:00 Assists in guarding against malpractice What was done By whom Were they adequately credentialed Records professional services Intake Differential diagnosis Placement criteria used in decision making Treatment and other services provided Response to treatment interventions Referral services and outcome Clinical course Reassessment and treatment plan reviews Records compliance with state, accreditation and payor requirements Ease transition to other programs and to referral resources Prevent duplication of information gathering when possible Facilitates Quality Assurance Documenting the appropriateness, clinical necessity and effectiveness of treatment Substantiating the need for further assessment and testing Support termination or transfer of services Identifying problems with service delivery by providing data to support corrective actions Adding to methods to improve and assure quality of care Providing information that is used in policy development, program planning and research Providing data for use in planning professional development activities. Fosters communication and collaboration between multidisciplinary team members Administrative Documentation Accurate, concise reports including recommendations, referrals, case consultations, legal reports, family sessions and discharge summaries Conducted at admission and at specified intervals through out care Types Client identifying and demographic information Referral source name and address Financial information Signed client rights Informed consent for treatment Releases of information Orientation to program Outcome measures Client placement information Clinical Documentation Screening Assessment Treatment Plan Progress Notes Discharge Summary Treatment Plan Plots out a roadmap for the treatment process Treatment plans are completed once A diagnosis is made Level of care is determined Client is admitted to the program Level of care is determined based on Diagnosis Client’s strengths and assets At minimum, the plan is a flexible document that uses a stage-match process to address: Identified Substance Use Disorders (SUDs) Recovery support environment Potential mental health conditions Potential medical issues Employment Discharge planning begins at admission Discharge planning begins at admission and continues throughout treatment Summarize Services delivered Accomplishment of goals and objectives Discharge recommendations (referrals, continuing care etc) Education Spirituality Social needs Legal needs Disposition of records by discontinued programs Addiction Counselor Certification Training $399 can be found at https://www.allceus.com/certificate-tracks/addictions-counselor-certification-training/