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Documentation is an essential component of the delivery of effective services, maintaining compliance with professional standards and reimbursement requirements. It is precisely why we are constantly reminded that “if it wasn’t documented, it wasn’t done.” Documenting the full scope of services provided and related outcomes can be complicated; particularly given the varying requirements of third-party payers, ethical requirements to professional standards, legal jurisdiction and client wishes. The Golden Thread of documentation provides a documentation framework that supports best practices in assessment, service planning, and delivery and ultimately reflects a comprehensive story of the client's progress throughout service engagement. The Golden Thread is as vital a resource for maintaining compliance and reimbursement as it is for ensuring the delivery of quality care.

Presented by: Earle Leitch, MS
Senior Training and Consultation Specialist
Rutgers School of Health Professions, Department of Psychiatric Rehabilitation and Counseling Professions.