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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
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Graduate Records Documentation MAC/MPC 528/Telecom Spring 2008
Mondays 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, progress reporting, defining the problem and validating diagnosis, and documenting the need for additional services.
Pre-requisite: None (Course location: Emilie Hall-distance learning room)
Course Objectives for Records Documentation:
Upon successful completion of this course, each student shall:
ALL STUDENTS
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Goal/Objectives: |
Learning Activities |
Evaluation |
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1. Understand the need for professional records documentation. |
Text Reading Video Lectures Class Discussions |
Exam Written Assignment |
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2. Demonstrate clear documentation of the course of client therapy. |
Class Discussion Video Lectures Experiential Activities |
Exam |
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3. Increase awareness and compliance with HIPAA and confidentiality. |
Text Reading Video Lectures Class Discussions & Handouts |
Exam Quiz |
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4. Gather and assess pertinent data needed to help identify the client's problem(s). |
Text Reading Video Lectures Class Discussion Handout activities |
Exam
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5. Outline a plan for effective course of treatment for the client's problem. |
Text Reading Video Lectures Experiential Activities |
Exam |
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6. Heighten communications with other helping professionals. |
Text Reading Video Lectures Experiential activities |
Exam Written Assignment |
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7. Further define the problem and validate the diagnosis. |
Text Reading Graduate Group Discussion
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Exam
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8. Document the need for additional services. |
Text Reading Graduate Group Discussion |
Exam
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Required Text: Wiger, Donald E. (2005) The Psychotherapy Documentation Primer
2nd Addition
John Wiley and Sons Inc, New York
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Course Evaluation Measures: Attendance/Participation 2 x 10 20 points Quiz 10 points Mid-term Exam 50 points Final Exam 70 points Papers 2 x 25 50 points Total possible points - 200 points |
Grading: Your final grade for this course will be assigned according to the following grade scale Graduate A = 180-200 B = 151-179 C = 132-150 D = 120-131
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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.
Written Assignments (Graduates) (50 points):
Specific writing guidelines for each of these papers will be discussed during class time and are listed below. Please have your copies of this syllabus available during each and every class meeting time.
General Guidelines for the Successful Submission of Written Assignments:
1. ALL papers are due at the beginning of class ON the due date listed beside each assignment. All written assignments must be submitted in hard copy—e-mail or faxed submissions are not acceptable (except for telecom classes). As a courtesy to those students who turn in their papers on time, all assignments submitted after the due date will lose points!
2. All papers must be typed or computer generated, APA style, with the student’s name, the course name and number, the title of the paper and/or the title of the assignment, and the complete submission date, including year, typed in the upper right hand corner of the first page of the assignment. PLEASE put your last name and the page number on each page!
3. All papers must be submitted on WHITE 8x11 standard typing paper. Do not submit your papers on anything else.
4. All multi-page written assignments must be stapled in the upper left hand corner. DO NOT submit any assignment with a cover, in a folder, on a computer disk, or in any other unusual way. Such papers will not be graded. Most importantly, DO NOT submit your assignment with a slick cover pinched together by a plastic rod! .
5. Keep copies of all written assignments submitted in this class for your own records. All written assignments will be graded in a timely fashion and returned at the professor’s convenience and discretion.
WRITTEN ASSIGNMENTS/GRADUATES STUDENTS ONLY:
Written assignment # 1 "The Process" (25 points—due 25 Feb 2008)
One of the essential components of an effective session with the client is a clear course of treatment through appropriate documentation. Your view, attitudes, and beliefs about the importance of documenting will affect the quality of the counseling relationship, the therapeutic effectiveness of your individual style, and the quality of your client outcome. You are required to reflect your new found knowledge and personal views about this process of documentation.
3-4 typed double-spaced pages.
This paper will answer the following questions:
Your view of this therapeutic process:
- What are the stages of the process and how important is each stage to you as the professional?
- How does your attitude about documenting effect the client really, if it does at all?
- Is their another process you would recommend as more effective?
- How does it feel to know how much you can affect the life of your client through this process?
Please use this paper to demonstrate integration of material and original thinking!
Remember that I am interested in your newly acquired knowledge and thoughts about the material.
Written assignment # 2 "Professional Correspondence" (25 points—due 21 Apr 2008)
Each professional needs to understand the impact of his/her communication with other professionals that might be seeing your client. Your communications style, attitudes, and beliefs can be valuable to your clients and to your business. You are required in this paper to 1)define your communication style, 2)define your attitude concerning your client, and 3) tell how your beliefs about how all this can or cannot effect you and your business.
3-4 typed, double-spaced page.
Please use this paper to demonstrate integration of material and original thinking!
Remember that I am interested in your newly acquired knowledge and thoughts about the material.
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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.
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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
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Class Meetings Week |
Review, Class Activities And Discussions Review Video # |
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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