Larry D Powell

Emilie Hall - Distance Learning Room

Office: M 1-4, Fri 9-12 (and by appointment)

Phone:  761-3218 (w) 231-2102 (h)

Fax:      406-761-6816

E-mail:  lpowell01@ugf.edu

 

 

Records Documentation ADC 164/Telecom Spring 2008:    Monday 8:00 A.M.

Documenting clinical records in a professional and ethical manner is essential for today’s counseling psychotherapist and helping professional. The information in this class will help develop documentation skills while advancing understanding of the need for conducting therapeutic process in a confidential manner. Information presented will include: developing the treatment process, HIPAA (Health Information Portability and Accountability Act) and confidentiality awareness, some understanding of third party requirements, exploring current documentation procedures, intake assessment via biopsychosocial and mental status exam, treatment planning, professional correspondence, and progress reporting.  

Pre-requisite: None         (Course location: Emilie Hall-distance learning room)

 

Course Objectives for Records Documentation:

 Upon successful completion of this course, each student shall:

 

Goal/Objectives:

Learning Activities

Evaluation

1. Understand the need for professional records documentation.

Text Reading

Video Lectures

Class Discussions

Exam

2. Demonstrate clear documentation of the course of client therapy.

Class Discussion

Video Lectures

Experiential Activities

Exam

3. Increase awareness and compliance with HIPAA and confidentiality.

Text Reading

Video Lectures

Class Discussions & Handouts

Exam

Quiz

4. Gather and assess pertinent data needed to help identify the client's problem(s).

Text Reading

Video Lectures

Class Discussion

Handout activities

Exam

 

5. Outline a plan for effective course of treatment for the client's problem.

Text Reading

Video Lectures

Experiential Activities

Exam

6. Heighten communications with other helping professionals.

Text Reading

Video Lectures

Experiential activities

Exam

 

Required Text:        Wiger, Donald (2005) The Psychotherapy Documentation Primer

                                                                     2nd Addition  John Wiley and Sons Inc, New York

 

 

Course Evaluation Measures:

Attendance/Participation                   20 points

Quiz                                                 10 points

Mid-term Exam                                50 points

Final Exam                                       70 points

Total possible undergrad points  150

    

Grading:

Your final grade for this course will be assigned

according to the following grade scale

                                 

                       A = 140-150

                       B = 129-139

                       C = 118-128

                       D = 107-117

 

 

Class Participation & Attendance   (10 points + 10 points = 20 points): 

Participation is a critical element of learning both in terms of knowledge and of skill development. Lively interaction is important to everyone in class!  Your fellow students and professor need you to give thoughtful and appropriate input and feedback. This course includes practice exercises and if you don't attend you can't participate. You can attend however and not participate, it's your choice but your grade will reflect that. Therefore, attendance and class participation will be taken into consideration for determining a final grade per points stated above.

HIPAA Quiz (10):

            Each student is responsible for developing and completing the HIPAA quiz in class. Each student is responsible for bringing 2 written appropriate questions concerning HIPAA and confidentiality with correct answers to class on the date indicated for open discussion. The professor will select 10 questions to comprise the quiz which will be completed in class after review. 

 

Miscellaneous Forms, Summaries, Correspondence

 

Mid-term Examination (50 points):

            Each student will complete a mid-term examination. This in class open book and open note exam will cover contextual interpretations of the text, lectures, demonstrations, and other class experiences. The exam will be a combination of short answer, essay, and multiple choice questions.

Final Examination        (70 points):  

Each student will complete a comprehensive final examination. This in class open book and open note exam will cover contextual interpretations of the text, lectures, demonstrations, and other class experiences. The exam will be a combination of short answer, essay, and multiple choice questions.

 

 

Accommodations for Students with Special Needs   Reasonable accommodation will be available to students with special needs as determined by the Center for Academic Excellence in Sullivan Hall (791-5213.) Please notify the professor as soon as possible of any adaptations that would help you in the classroom or if she can be of assistance in any other way.

 

Student Responsibilities   By registering for this class, all students agree to learn and follow the academic honesty, conduct, and responsibilities policies as stated in the UGF catalog and student manual.

 

 

 

 

                              Class Schedule Spring 2008

 

Class

Meetings

Week

Review, Class Activities

And Discussions

Review Video #

 

Review Reading

Chapter #

Notes

 

1 - Jan 14    INTRODUCTION - PROFESSOR, STUDENTS, AND COURSE

 

2 - Jan 21    ***   NO CLASS  Martin Luther King Day   ***

 

3 - Jan 28    Video #1 and #2 Intro                                          Chpt #1 and #2   

 

4 – Feb 4     Video #3 and #4 Confidentiality/HIPAA

 

5 - Feb 11    Video #5, #6 and #7 Biopsychosocial, Mental Status Exam  Chpt #3 and Chpt #4

 

6 – Feb 18   ***   NO CLASS Presidents Day   ***           

 

7 - Feb 25    ***   MIDTERM   -    GRADUATE PAPER #1 DUE   ***

 

    

8 - Mar 3     ***   SPRING BREAK - RELAX  -  CHILL - ZONE OUT - VACATION  -   PARTY   ***

 

 

9 - Mar 10    ***  GRADUATE STUDENTS ONLY - REVIEW CHAPTER #5 and #8   ***

 

10 - Mar 17  - Chpt #6 and  Chpt #7

 

11 - Mar 24   ***  NO CLASS Easter   *** 

 

12 - Mar 31  Video #8 and #9 Treatment Planning  

 

13 - Apr 7    Tx Plan Exercises

 

14 - Apr 14   Video #10 and #11 Progress Notes   Progress Note Exercises

 

14 - Apr 21    ***   FINAL EXAM REVIEW  - GRADUATE PAPER #2 DUE   ***

 

 

15 – APR 28      FINAL EXAM                          FINAL EXAM                              FINAL EXAM