HS 115 - Principles of Client Record Mgmt

Admission to a Human Services program.

Course Description: Familiarizes students with the key concepts of clinical documentation related to screening and intake processes, assessments, treatment plans, reports, progress notes, discharge summaries, and other client-related data. Oregon Department of Human Services, American Society of Addiction Medicine, and other professionally relevant criteria will be introduced. Students will learn to respect clients’ right to privacy and confidentiality, and to appreciate the importance of accurate, timely documentation and the necessity of safeguarding client records.

Course Learning Outcomes:

• CLO#1: Explain the rationale for accurate record keeping.
• CLO#2: Describe the basic contents of client records, including industry terminology, common abbreviations, etc.
• CLO#3: Identify and describe the client’s right to privacy and the importance of confidentiality.
• CLO#4: Recognize ASAM criteria, Mini-mental Status exam, and DSM. (ILO: Information Literacy)
• CLO#5: Demonstrate the use of outcome measures.