Online Course » Clinical Documentation: Writing Encounter Notes

This course provides an overview of how documentation fits within the bigger picture of an individual's care and focuses specifically on strategies and best practices for writing high quality encounter notes.

***If you are experiencing issues with the training, please email the DBH Training Institute at dbh.training@dc.gov for further assistance. ***

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.

Direct Service Staff