Documentation Standards & Clinical Compliance Training

Training Topics

Month 2 – Documentation Standards and Clinical Compliance Focus: Ensuring clear, timely, and compliant documentation. Topics • Documentation best practices: timeliness, content, and corrections • Progress note vs. therapy note • Documenting health/safety, coordination of care, psychiatric evaluations, and medication consents • Addressing service deviations (addendums, ABDs, corrective actions) Objectives • Strengthen documentation alignment with clinical standards and payer requirements • Improve audit readiness and chart defensibility Relevant Review Citations • CWP P.1.3 / iSPA P1.A1 / SEDW P.3.3: Best practice for documentation of health/safety, coordination of care, psychiatric evaluations, and medication consent. o Documentation Best Practices (Themes): Golden Thread, Timeliness, Progress note vs. therapy note, and Provider prescriptions. o Monitoring Authorizations and Appropriate Documentation: Addressing service deviations and documenting corrective plans (addendum