CDA Licensing Training

Unit 4 : Documentation and Reporting

Instructor: Alia El Naggar

Objectives

● At the end of this unit, participants

will demonstrate an understanding
of the procedures of data collection
and documentation.
Content
● Introduction

● Types of documentation

● Break

● Methods of documentation

● Elements of Effective Documentation

● Questions
Why do we document?
What are the types of documentation ?

● In 3 groups, discuss the types of documentation.

● Mention/write down the different types of

documentations used
Mental Health Documentation
Documentation for mental health issues include the following:

● Psychological Assessment (completed by professionals)

● Mental Health Progress Notes by Psychologist

● Cognitive Assessments by Psychologists

● Behavior tracking record by therapists

 Elements of Effective Documentation

● Descriptive words, It is important to use descriptive words and

to avoid general words .

● Be specific in documentation : instead of writing the ‘client

was angry’ write the way this was exhibited, reason for behavior
etc.

• Accuracy

• Organization

• Complete
Activity: Elements of Effective Documentation

Use of Common Vocabulary

● Improves communication and lessens the chance of misunderstanding

between members of the health team.

● In 4 groups, write a list of examples for common vocabulary related to

your field and the replacement that facilitates understanding

Technical term Replacement term

Comprehensive evaluation An assessment of the client’s complete functioning

and skills, e.g. language, motor and social skills.

Prompting A procedure used to facilitate the client selecting

the correct answer
Break
Assessments and screening

● Psychological assessments aim to recognize, characterize, and measure

a person’s versatile and maladaptive practices and treatment objectives.

● Essentially, it is the systematic evaluation of someone’s conduct.

● These are usually done by psychologists and psychiatrists.

Some Methods of Documentation
PIE Charting
P: Problem statement, I: Intervention, E: Evaluation

Example:
P: Child screams to seek attention 9 / 10
I : Team agreed to extinct/ ignore the behavior and applied it
for two weeks
E : Child attention seeking behavior decreased 1 / 10

Give examples for another PIE

Final Group activity:

Watch the video and:

1- Discusses which type of documentation is suitable for

this case?

2- Create a documentation (form) that will help all the

team to understand this case and how to assess, measure
progress and evaluate the intervention

https://youtu.be/ua9zr16jC1M
 Assignment
Write the case management process used at your
workplace, explaining the documentations used in each
step
Questions?