We need to stop thinking of clinical documentation as paperwork and start thinking about it as the clinical work.
Be prepared to be more transparent as a provider.
Be prepared to decrease how much you are writing. A great note does not mean a long note.
Remember that it is OK to agree to disagree.
Be prepared to shift your language to client friendly language that will still maintain medical necessity. Use clients language and terms that client can understand and/or relate to because using technical terminology can negatively impact treatment.
Introduce the plan for meeting including how you will work collaboratively to accurately represent the information they are telling you today.
The limited typist can talk and then review and type before moving to the next session.
Interpretative/Clinical Summary Say, OK, let sum up what weve discussed today. Document with the client.
Areas) that can be used to establish goals.
need. This will be the link from the assessment to the goal.
an identified need in the clinical assessment.
A goal statement takes a particular identified need and answers the question, What do we want the outcome of our work together to be, as we address this identified need?
Discuss and enter a collaborative statement that makes sense to the client.
Remember: Objectives are important to allow you and the client to tell if the work you are doing together is working.
Document with the client. Help them understand that this is what you will do to help them achieve their objectives (Walk up the staircase).
Review recommended frequency and confirm the commitment.
plan becomes irrelevant update it!
How do I do a CD progress Note?
5. Clients response to intervention (today) What did we do today that was helpful?
Assume that your clients will read their documentation.
Start the process with new clients right away.
What if a client says I dont want to document during the session?
How do I use CD with parents/families?
How do I use CD in Collateral Meetings?
How do I do CD in groups?
How do you do CD during a telephone call?