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Documentation--Florida Certification Board CAP
Documentation in the clinical record is an integral part of delivering substance abuse treatment services. Documentation organizes and evaluates clinical work by demonstrating that the services delivered are effective and efficient.
The Florida Certification Board approves this course and meets the 15-hour requirement for the Documentation Domain for the initial application for the CAP credentials. Please see the Florida Certification Board for full details on these credentials, including formal education, other content-specific training domains required, work experience, supervision, and required exams.
This course will award 15 continuing education hours.
Please see the board approval box for course approvals.Course Objectives
- Understand the importance and legal implications of accurate and thorough documentation in substance abuse counseling: Participants will learn about the legal and ethical requirements for documentation in substance abuse counseling, including confidentiality laws (such as HIPAA), informed consent procedures, and mandated reporting obligations. They will also explore the role of documentation in promoting accountability, continuity of care, and effective communication among treatment team members, clients, and other stakeholders.
- Develop skills in effective documentation techniques for substance abuse treatment: Participants will learn practical strategies for documenting client assessments, treatment plans, progress notes, and discharge summaries in accordance with industry standards and best practices. They will learn how to use standardized assessment tools, formulate measurable treatment goals, and document client progress and outcomes over time. Participants will also explore various formats and styles of documentation, including narrative notes, checklists, and electronic health records (EHRs), and develop proficiency in using documentation templates and software systems.
- Enhance communication skills for conveying clinical information through documentation: Participants will learn how to effectively communicate clinical information through written documentation, ensuring clarity, accuracy, and relevance for diverse audiences. They will explore techniques for organizing and structuring documentation to convey key information concisely and comprehensively, using language that is client-centered, objective, and non-judgmental. Participants will also learn how to tailor documentation to meet the needs of different stakeholders, such as treatment team members, referral sources, insurance providers, and regulatory agencies.
- Foster critical thinking and decision-making skills in documentation: Participants will develop the ability to critically evaluate and analyze clinical information, assess client needs and progress, and make informed decisions in documentation. They will learn how to identify and prioritize relevant information, recognize red flags or warning signs of potential risk or relapse, and document interventions and outcomes effectively. Participants will also explore ethical dilemmas and challenges in documentation, such as managing confidentiality breaches, handling dual relationships, and addressing discrepancies or inconsistencies in client reports, and develop strategies for navigating these issues ethically and responsibly.
Course Author
Information
- Relevance: This course is approved by the Florida Certification Board for those seeking a Certified Addiction Professional credential. It meets the 15 hour requirement for the Documentation Domain.
- Content Level: Intermediate
- Course Format: This course is offered as a self-paced distance learning format (reading-based online activity)
- System Requirements: This course is offered online. Internet connection required.
- Course Completion Information: To earn continuing education credit, professionals must register and pay the fee for the course. They must read the content and demonstrate understanding by earning a minimum score of 70 percent on testing materials. The certificate of completion will be able to be downloaded after the above is completed. Refunds will be granted upon request with the withdrawal of credit for the course. For questions, concerns, or to request special accommodations, please call 866-863-4225 or email [email protected].
- Credit Hours: 15
This course is approved by the Florida Certification Board for those seeking a Certified Addiction Professional credential. It meets the 15 hour requirement for the Documentation Domain.