CADC – Documentation 100% Verified
Roles of documentation 1. clinical tool
2. continuity of care
3. legal document
4. accountability
5. quality assurance
Documentation as a clinical tool chronologically details the condition of the
client receiving
services, why the services were needed...
Documentation as a clinical tool ✔✔chronologically details the condition of the
client receiving
services, why the services were needed, services provided who delivered the
services, and
outcomes achieved.
- used in supervision
- most important skill in assuring continuity of care
Documentation as means to ensure continuity of care ✔✔ensures continuity of
care, regardless of
counselor availability, changes in counselor or service provider or subsequent
readmission for
, CADC – Documentation 100% Verified
services.
- EASES the TRANSITION PROCESS ensuring pertinent info is available to
receiving
counselor/program
Documentation as a legal document ✔✔records both counselor and client input,
including what
did/did not work.
- portions of clt record may be requested by courts if clt is legally involved or in
cases where the
clt brings legal proceedings against a counselor/program
Documentation as accountability ✔✔recording information that is used for
billing purposes,
financial audits or reviews to ensure compliance with various standards.
- document time, date, duration & type of insurance
Documentation for quality assurance ✔✔the clt record provides documentation
for quality
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