About this course

Learning Objectives

• Identify common documentation errors that increase audit/compliant risk
• Differentiate progress notes vs. psychotherapy notes and describe appropriate content boundaries for the medical record
• Write documentation language that links assessment/diagnosis/intervention/response/plan
• Document risk screening and safety decision-making with clear rationale and follow-up steps
• Documentation Integrity Check application

Learning Levels

• Learning Level: Intermediate This course is designed for licensed social workers who possess foundational knowledge of clinical documentation and professional recordkeeping. Participants will build upon existing documentation skills by examining high-risk documentation errors, strengthening medical necessity language, improving risk documentation practices, and applying evidence-informed strategies for defensible clinical writing. The course emphasizes practical application, clinical judgment, ethical responsibilities, and regulatory considerations relevant to contemporary social work practice.

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.

References

• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing. 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). Medicare Benefit Policy Manual. CMS. Centers for Medicare & Medicaid Services. (2024). Documentation guidelines for evaluation and management services. CMS. Joint Commission. (2024). Comprehensive accreditation manual for behavioral health care and human services. Joint Commission Resources. Louisiana State Board of Social Work Examiners. (2025). Louisiana Social Work Practice Act and Rules. Author. Louisiana Department of Health. (2025). Behavioral Health Provider Manual. Author. National Association of Social Workers. (2021). Code of ethics of the National Association of Social Workers. NASW Press. Reamer, F. G. (2023). Social work documentation and record keeping: Risk management strategies for clinical practice. NASW Press. Reamer, F. G. (2018). Ethics and risk management in online and digital social work. Cognella.