Clinical Documentation: Writing Encounter Notes

Course Objective:

At the end of this training, learners will be able:

• Describe the foundational steps to good documentation.
• Explain how encounter notes fit within the bigger picture of quality care.
• Define an encounter note.
• Explain how encounter notes are used by persons in care, direct service staff, provider agencies, and the government (Medicaid).
• Write encounter notes that follow the "SIRP" structure.
• Demonstrate best practices and effective strategies for writing detailed encounter notes.