Documentation Done Right Workbook Series

Documentation is one of the most important components of delivering behavioral health services. All behavioral health providers are required to meet regulatory standards of practice that include appropriate documentation.

Documentation Done Right is a set of workbooks designed to share best practices in documentation and provide users with exercises that provide an opportunity to practice these skills. Each stand-alone Documentation Done Right workbook targets a specific skill area. Choose the workbook that addresses the topic where you need practice.

Explore each of the resources by clicking on the download links below:

Workbooks

• Maintaining the Golden Thread (Word) (PDF)
  • Aimed at making sure progress notes connect back to the treatment goals.
     
• What’s In, and What’s Out (Word) (PDF)
  • Designed to help providers focus on and include only relevant information.
     
• Avoiding Assumptions and Judgments (Word) (PDF)  
  • Intended to help writers keep the focus on facts and avoid speculation.
     
• Proofreading Progress Notes (Word) (PDF)
  • Details strategies to avoid typos, grammar problems, missing words and other issues.
     
• Documenting Unexpected Needs (Word) (PDF)
  • Specifies how to document crises and other unexpected events.
     
• Documenting Service Encounters with Others (Word) (PDF) NEW!
  • Describes the necessary information to include when others are involved in service provision.
     
• ​Using Strengths-Based Language (Word) (PDF) NEW!​
  • Helps providers understand the importance of embracing strengths-based language in documentation.
     
• Documenting Family Peer Support Services (Word) (PDF) NEW!
  • Focuses on the key elements for documenting Family Peer Support Services.

Tip Sheets

• Essential Tips Documenting Evidenced Based Practices (Tip Sheet) (Word) (PDF) NEW!
  • Specifies tips for documenting the use of Evidence Based Practices in progress notes.
• Essential Tips Documenting Non-Reimbursable Activities (Tip Sheet) (Word) (PDF) NEW!
  • Identifies how to document activities that are beneficial and connected to an individual’s treatment but may not be reimbursable by third party payors.

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