MHAW107 – Record Keeping and Documentation

COURSE INFORMATION:

Admission Requirements
  • Grade 12 or OSSD Equivalent
  • Mature Student with Wonderlic SLE min. cut score minimum 14 on test
  • Bring your own device (BYOD): As a student in this on-campus program, you will require a mobile computing device that meets specifications outline by your program

Delivery Mode: Online
Textbook: eBook: Professional Writing Skills for Social Workers 1st Edition McGraw Publishing 2015

Course Fees: $485.00 (with eTextbook)
Other Compulsory Fees: Registration Fee: $100.00, Shipping/Handling Fee $61.00
Additional Cost: Textbook $175.00 (Hard Copy)
Course Hours: 45 Hours
Course Intake: Every Monday
Department: PT – Continuing Education
Registration: Nativetc.com



COURSE OVERVIEW

In this subject, students will learn the art of creating and maintaining accurate, up-to-date, and  comprehensive client records that meet legal scrutiny.


TRAINING LOCATIONS

North Bay Campus or Online – www.nativetc.com


Knowledge Competencies

Creating and maintaining accurate, up-to date, comprehensive client records able to withstand legal scrutiny:

  • Assists in updating less sensitive client records (e.g., intake reports, release forms, progress notes)
  • Adheres to all requirements and protocols about where, when, and how client records are to be safeguarded
  • Enters, accurately and legibly, all required elements of client records into information systems in a timely manner
  • Obtains informed consent from clients and documentation required for exchanging information (e.g., during the referral process)
  • Discusses the boundaries of confidentiality with clients to ensure they understand the circumstances in which information will or will not be shared. Advises supervisor of any conflict of interest and follows appropriate protocols
  • Updates sensitive client records (e.g., screening and assessment reports, court mandated reports)
  • Uses appropriate terminology and approved abbreviations in client records and documentation
  • Records all client-related information in a professional manner that reflects organizational protocols, established regulatory practices, and record keeping guidelines
  • Documents all stages of the treatment process clearly, accurately, and concisely, ensuring entries are legible if handwritten or accurately typed and coded for electronic systems