This interactive presentation will examine best practices for record keeping in clinical practice. This training will provide a comprehensive overview of the legal as well as ethical requirements of health care records

Participants will come away with an understanding of how records can be applied to clinical practice and risk management.

This training will not focus on HIPAA, though it will touch on HIPAA requirements regarding privacy and disclosure.

Goals and Objectives:

  • Provide a comprehensive overview of the legal requirements of disclosure and informed consent, discussing purpose, function and utility. Attendees should come away with a clear understanding of what is required, such that they can review and edit their own disclosure statement and ensure it is in compliance.
  • Provide a comprehensive overview of the legal and ethical limits to confidentiality. Attendees should come away with a clear understanding of when disclosure may or must be made without client authorization.
  • Provide a comprehensive overview of the legal requirements and ethical relevance of health care records, as well as differing philosophies about what to record. Attendees should come away with a clear understanding of how they can best comply with the law and also protect themselves and their practice and still render the best care and service they can.
  • Provide a comprehensive overview of the legal requirements and ethical concerns related to disclosure to third parties. Attendee should come away with a clear understanding of the legal and ethical issues involved in the release of information to third parties, and how to review their own forms for compliance.
  • Provide a comprehensive overview of the legal and ethical issues of documentation of protected health information to third party payors. Attendees should come away with a clear understanding of how to comply with disclosure, as well as how to maintain client confidentiality to the fullest extent possible.
  • Provide a comprehensive overview of development and use of treatment plans. Attendees should come away with a clear understanding of how to compose a treatment plan that is symptom-based and meets criteria for medical necessity.

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