‘Not documented – not done’: hardly any phrase shapes everyday care as much as this one. But good documentation is more than protection – it is a management tool, a means of communication and evidence of quality all at once. This course (approx. 12 teaching units of 45 minutes each) takes you through the entire field in 12 modules: from the purpose and legal bases of documentation (Social Code Books V and XI, i.e. SGB V and SGB XI; liability law and the law of evidence) through the four elements of the Structural Model (Strukturmodell) – the structured information collection (Strukturierte Informationssammlung, SIS), the individual care plan, the progress report with the deviation principle and evaluation – to care planning, the risk matrix, dealing with the Medical Service (Medizinischer Dienst, MD) and typical documentation errors. Each module offers learning objectives, well-founded study text with visualisations, an In depth section, a Case study and a Transfer-to-practice exercise. At the end: a comprehensive self-reflection, checklists for everyday practice and your confirmation of participation.
Course objectives:
- Understand the purpose, functions and legal bases of care documentation with confidence
- Apply the four elements of the Structural Model (SIS, care plan, report, evaluation) with confidence
- Implement the deviation principle correctly and reduce the reporting workload
- Appraise risks professionally and reflect them in the care plan
- Write in a legally sound, factual and evidentially robust way – avoiding sources of error
- Prepare confidently for quality inspections (MD)
Self-study without supervision, assignments or assessment of learning progress by instructors; the voluntary self-reflection is for your own orientation only. Your confirmation of participation becomes available once you have marked all modules as done yourself.
Scope: 12 modules of about 45 minutes each (approx. 12 teaching units of 45 minutes each, about 9 hours).