University:
York University
Course:
PPSYC 3140 | Psychological Health, Distress, & Impairment
Academic year:

2023
Views:

115

Pages:

2
Author:

Nick T.

Documentation & Termination Document What? document meetings/sessions with the client document "client progress (or lack of progress), new issue, salient interventions" document phone calls/outside communication document contacts with others on treatment team document case notes, progress notes, charting, etc. if you don't write it, it didn't happen Why Document? to uphold our primary responsibility to clients to track progress on goals to document interventions and results of interventions to document collaborations with other care providers to keep conversations on track/on task to demonstrate ethical care to protect yourself as a provider the fundamental purpose of a case note is to create a record of the clinical management of the overall case Documentation Styles S.O.A.P. method (subjective, objective, assessment, plan) D.A.P. method (data, assessment, plan) B.A.R. method (behavior, action, response) S.T.I.P.S. method (Signs & Symptoms, topics of discussion, Interventions, progress & plan, special issues) What to Include basic demographic info (who was in session, date, duration, payment info, diagnosis, session #, etc.) Client presentation (appearance, mood, affect, judgment, orientation, cooperation) topics of discussion + how they related to the treatment plan/goals (subjective) interventions during session and/or homework (plan) Clinical observations (objective) progress or setbacks, new strengths or challenges Tips Complete case notes within 24 hours Records must be kept for 7 years+ Write in 3rd person, be concise, use role names (client, wife, father, son, etc.) instead of names Include enough so that there are no questions about what went on during the session, but avoid judgmental statements - stay professional and consider others who will read your note. Sometimes less is more Carefully review and edit before saving Special Considerations Threats of harm to self or others, reports of abuse/neglect, drug use & sexual activity reported by a minor, custody issues require special attention in case records Addition of novel intervention (e.g., EMDR or brainspotting) not included in original tx plan document Document lack of progress and how you are helping client work through the lack of progress