As health care moves to electronic medical records, organizations and practitioners need help to make certain their clinical documentation is accurate. Inaccurate documentation can lead to improper reimbursement, HIPAA concerns, or legal or security issues. Through a U.S. Department of Labor grant, Front Range Community College, in partnership with industry experts located throughout Northern Colorado, developed training to assist clinicians with clinical documentation.
Clinicians Learn Proper Documentation
Clinical documentation was prioritized by our industry advisors as one of the most important training topics affecting health-care organizations today. This training will provide a basic understanding and a good foundation for proper clinical documentation.
The training will be useful for therapists, nurses, and other health-care professionals as well as other staff involved in documenting patient progress. These trainings are approved for Continuing Education Credit by the Colorado Nurses Association.
Training is Free
The cost of this training is currently covered through a grant and is available at no cost to the healthcare facility or individual. However, the registration process will include an individual grant application requiring applicant demographic information. Contact us to discuss and register for this training.
Training Module 1:
Why is Clinical Documentation Important?
This one-hour introduction describes the principals of documentation and discusses the benefits and barriers to accurate clinical documentation. A short quiz must be completed successfully before moving on to Module 2. See course demo.
- Describe why accurate clinical documentation is important
- Examine why patient care has become more complex
- Follow governmental guidelines
- Explore the benefits of moving to Electronic Medical Records
Training Module 2:
What Does Accurate Clinical Documentation Look Like?
This two-hour course teaches accurate clinical documentation. It examines do’s and don’ts of clinical documentation. Documentation strategies and best practices are outlined. The components of documentation are identified, as are ways to enter data and chart completely to receive reimbursement. Confidentiality issues are examined. Proper coding, charting for reimbursement and the “must haves” of charting will be discussed. A short quiz will end the module. See course demo.
- Describe why accurate clinical documentation matters
- Examine types of documentation
- Describe documentation issues
- Identify documentation components
- Examine documentation strategies
- Practice documenting patient information
- Demonstrate how to accurately document in a patient’s record