Documentation Standards & Clinical Compliance Training

Info: 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 Medic*tion 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 Medic*tion 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

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Host or Publisher Northern Michigan Regional Entity