Record Keeping

For your initial post to this discussion, briefly describe the record-keeping practices that are used at your current fieldwork site.

How does the site collect and store information about clients? Information is collected online, or when the client comes to the office, and on the phone. The site is a confidential site, The forms is printed out in the office and added into a chart that is stored into a locked cabinet

How do they keep track of payments made, insurance companies billed, release forms that have been signed, or formal communications sent out about clients? There is a biller who uses a billing website. The system for making sure all clients are billed is, every time a client is seen by a therapist a progress note is done and a ticket is filed by the therapist. and handed to the biller the owner check the sign in sheet and the calendar to make sure that all client that was seen was billed. One must even submitted a ticket and a progress note for no shows which are called non-billable.

Describe some of the skills you have developed regarding record keeping and case management methods in order to meet your site’s requirements. one skilled that I have developed is completing progress notes and billable tickets.

What aspects of record keeping have been challenging for you? one aspect that has been a challenging for me is developing a treatment plan with the client on the third visit.

Discuss the steps you will take in order to continue improving your record-keeping skills. I will practice having a computer and pad in session with me i still feel uncomfortable with a computer in the room.

Please use 2 reference and make one page.


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