Three major purposes of documentation
Documentation has three major purposes. The first and most important is to facilitate the planning and delivery of coordinated, quality services that meet the client’s assessed needs and preferences. Strong documentation:
- Articulates clearly who the client is as a person and what the client wants from services.
- Shows what services are planned; appropriate interventions and services are provided.
- Communicates the course of services and client progress to involved stakeholders.
- Confirms that reassessments occurred on an ongoing basis, and that information is current.
- Identifies outcomes and helps establish discharge criteria.
Secondly, documentation serves as a legal document, supporting billing and compliance with regulations. Documentation:
- Provides a written legal record of the assessment, planning, referral and monitoring services provided.
- Documents eligibility and necessity of services;
- Demonstrates that outcomes are identified.
- Provides clear evidence that the services billed were the services provided.
Thirdly, documentation serves as an indicator for supervisors and practitioners of the case management practices that are occurring.