Explore The Clinician's Development Center
The Essentials of Documentation is the signature course, designed to elevate the quality of clinical documentation. Created by a social worker, for social workers, originally designed for students and recent graduates, it has gained a reputation as being appropriate and beneficial for a range of other social service and mental health professionals, from entry level to the more experienced practitioner providing clinical supervision.
The course provides extensive details, beyond common formatting styles that are mentioned in school and placement, and is intended to help you transition from the classroom and the clinician. You only need to complete one format of The Essentials course, but this is just one aspect of your assessment and documentation learning journey. You are encouraged to consider taking other courses to ensure you gain the most comprehensive understanding of the process and rationale behind conducting thorough assessments and producing quality documentation that will perform well in an audit or ethical review. The information is provided with a goal of helping you audit-proof documentation while protecting clients, the provider, and the agency.
Additional courses are in development and will be announced upon availability. Select training sessions offered through The SSSW(see below) may be purchased and attended by non-members. Recordings of courses will be posted and available for purchase as they become available. Check the website regularly, follow MarcytheMSW on social media for announcements, discounts, and special offers. Office hours, role-playing, career focused and other customized sessions are available, may be requested and purchased as 1:1 or small group (up to 5 people) coaching.
The Essentials of Documentation (Overview)
The online course is an eLearning experience. It is a self-paced, interactive, distance learning course presented in a hybrid, asynchornous format, consisting of readings and pre-recorded videos. Participants must independently read each section and watch the videos in order, then pass the knowledge checks before moving forward.
Individuals who enroll in this course will not have an opportunity to ask questions while taking the course, but may submit relevant questions and participate in a follow up Q & A session offered quarterly.
The Essentials - Online
Welcome:
The Essentials of Documentation
Why This Training and Why Now?
The Functions of Documentation:
The Evolution of Documentation Practices
The Functions and Value of Documentation
The Assessment - Key Components:
Assessing Basic vs Clinical Needs
Medical Necessity
A Brief Overview of the Mental Status Exam
The Mental Status Exam & The Mini Mental Status Exam
Cultural Considerations
Progress Notes - The Format:
Formatting the Progress Note
Organization of Content
Understanding Acronyms
Progress Notes - The Content:
Content of the Notes
Writing Enough, but Not Too Much
Exercising Caution in Crisis
Maintaining Personal Notes
Credibility:
Timeliness of Documentation
Language and Terminology
Grammar, Punctuation, & Correcting Mistakes
Access to Records:
Responding to Subpoenas
The Cures Act
Open Notes and Descriptive Documentation
Safeguards in the Digital Age:
Privacy and Boundaries
Digital (Ethical) Dilemmas and Safeguards
The Essentials of Documentation LIVE Presentation
Course Agenda
LIVE training sessions are presented IN-PERSON or VIRTUALLY once per quarter in February, May, August, and November. These live sessions are best for those who want the opportunity to ask questions on the spot and engage directly with me. During live presentations, questions asked along the way will be answered during the session, as possible or at the end of the session during the Q & A.
The Essentials - Live
The SSSW is a comprehensive training and professional development membership program for social work students and recent graduates. Training offered monthly is designed to coincide with typical BSW or MSW programs. Between training sessions and office hours you will gain more in depth knowledge and learn strategies to develop your assessment and documentation skills, increase your ability to manage crises, maximize your learning in supervision, and be hired or placed in your preferred social work setting.
Non-members of SSSW may purchase select training sessions offered individually.