3 Tips for Clinical Documentation in Trauma Treatment

Published by ninakeeler on

For many of us, being a trauma treatment professional means having to also know how to do paperwork.  Quality clinical documentation can save you from a lot of headaches. 

I didn’t really understand the hidden benefits of good documentation until I worked for a community-based organization that was a Medicaid provider.  If you have ever had the “pleasure”, and I use that word loosely, to have a job like this you know the paperwork machine can sometimes almost over-shadow the direct work with our clients.

However, I was in management at this job so I got to peak behind the curtain and see how good clinical documentation increased effectiveness of treatment, safety for the client and provider, and the overall success of the case.

You may be wondering how clinical documentation can do all of this…well I think documentation has gotten a bad reputation over the years, and it is time to embrace what it can do for us and the work we do with our clients, especially those who have survived trauma.

Check out this week’s vlog below where I share three of my tried and tested tips for efficient and effective clinical documentation within trauma treatment.

Categories: Training

1 Comment

Cheryl Y Howard · December 11, 2019 at 4:32 am

I’m already feel burned out from Documention and have been looking for exiting and transitioning strategies where documentation is less. I just expressed this to colleagues, family members and friends. I have never been an admin and office type… because I’m a creative and artistic. I’m an “in front of the camera person.” It’s something how we find out more about who we are as we get older and through life’s journey. The performing arts person inside of me still screams lol. Now I still enjoy (most of the time), working one on one/direct care with clients. I love the empowerment and emotional healing piece and the positive outcomes of working with clients are the only thing that keeps me motivated as I transition out… The video presentation was great Nina. Thanks for sharing. I will keep the steps you shared in mind as I complete ISP’S, Session notes, Quarterly reports and Progress reports…

Leave a Reply

Your email address will not be published. Required fields are marked *