The Golden Thread: Clinical Documentation Improvement

Training Delivery Format = Online/On Demand (ASynchronous).  This course is primarily designed for clinicians. 

The Golden Thread

The Golden Thread is a term that represent the linking of all the concepts in medical record documentation. Each piece of documentation flow’s logically form one to another such that someone reviewing the record can see the logical progression and understand the story that is being told about the individual’s treatment and progress.

1. Assessment:  must identify the critical clinical needs of the individual based on their presentation and history.

1. IPOS:  must reflect Goals and Objective that address the concerns of the individual identified in the assessment. Using the words or quotes form the person or guardian. This is done by developing measurable, attainable goals and objectives that provide the opportunity for the individual to actively focus on the needs reflected in their assessment in a targeted manner.  The treatment plan must have coherent and cohesive in order to establish medical necessity.

1. Progress notes:  must flow from the treatment plan by reflecting progress toward the identified goals and objectives and the individuals response to treatment as well as describing services that are authorized in the plan.

Progress Notes tie to the treatment plan reviews and assessment updates which review the progress described in the notes at a particular time, reiterate needs and goals, and establish the continuing need for services.The treatment plans may need to be updated as a result of the treatment plan review of the assessment update if new issues and new strategies are identified and developed with the individual.

The Golden Thread weaves through our service to the individuals we support as it represents the linking of the concepts in Medical Record documentation. This course is designed to improve your clinical documentation, achieve the standards that lead to the Gold Thread through your assessments, IPOS developments, progress notes, and periodic reviews. The concepts of Medical Necessity and Medicaid Waste and Abuse are included.

Course Length is 1 hour and is approved for 1 Social Work CE.