About this course

Learning Objectives

• Describe the purpose and clinical function of progress note documentation.
• Apply an Assessment–Intervention–Response–Plan framework to clinical notes.
• Differentiate vague documentation from clinically meaningful documentation.
• Write documentation that connects symptoms, functional impact, intervention, response, and next steps.
• Improve documentation quality across healthcare, hospice, school, outpatient, and community-based settings.

Learning Levels

• Learning Level: Intermediate This course is designed for licensed social workers who possess foundational knowledge of clinical documentation and treatment planning. Participants will strengthen their ability to document assessment findings, interventions, client responses, clinical reasoning, progress toward goals, and follow-up plans using evidence-informed documentation practices. The course emphasizes practical application of documentation frameworks, measurement-based care, medical necessity, and clinical decision-making to improve documentation quality and support effective treatment outcomes.

Course Instructor(s)

• 

  Donna W. Wimberly, MSW, LCSW-BACS

  Donna Wimberly is a Licensed Clinical Social Worker and Board Approved Clinical Supervisor with extensive experience in clinical practice, leadership, and social work management. As graduate of Louisiana State University School of Social Work, owner of her own private practice, and Manager of Social Work Services, Donna strives to enhance clinical outcomes and foster team development while dedicating her career to advancing mental health and social work practice. Donna is a member of the National Association of Social Workers and has served as member of the NASW-Louisiana Board, the Regional Chair for the Lafayette Chapter, as well as past committee member for multiple NASW-Louisiana committees. Donna is a current member of the LABSWE Rules Committee. Donna has vast experience authoring and presenting continuing education programs across the state.

Disclosure

References

• American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). Author. Association of Social Work Boards. (2024). Model social work practice act. Author. Centers for Medicare & Medicaid Services. (2024). Documentation guidelines for evaluation and management services. CMS. Centers for Medicare & Medicaid Services. (2024). Medicare benefit policy manual. CMS. Joint Commission. (2024). Comprehensive accreditation manual for behavioral health care and human services. Joint Commission Resources. Louisiana Department of Health. (2025). Behavioral health provider manual. Author. Louisiana State Board of Social Work Examiners. (2025). Louisiana social work practice act and rules. Author. National Association of Social Workers. (2021). Code of ethics of the National Association of Social Workers. NASW Press.
• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing. Boswell, James F., Kraus, D. R., Miller, S. D., & Lambert, M. J. (2015). Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy Research, 25(1), 6–19. Fortney, John C., Unützer, J., Wrenn, G., Pyne, J. M., Smith, G. R., Schoenbaum, M., & Harbin, H. T. (2017). A tipping point for measurement-based care. Psychiatric Services, 68(2), 179–188. Reamer, F. G. (2018). Ethics and risk management in online and digital social work. Cognella Academic Publishing. Reamer, F. G. (2023). Social work documentation and record keeping: Risk management strategies for clinical practice. NASW Press.