1=Understands 2=Developing 3=Competent 4=Skilled 5=Master
Practice Dimension VII: DOCUMENTATION
The recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client-related data.
Demonstrate knowledge of accepted principles of client record management.
Protect client rights to privacy and confidentiality in the preparation and handling of records, especially in relation to the communication of client information with third parties.
Prepare accurate and concise screening, intake, and assessment reports.
Record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.
Record progress of client in relation to treatment goals and objectives.
Prepare accurate and concise discharge summaries.
Document treatment outcome, using accepted methods and instruments.