1.03 - Ch. 2 - Reporting Systems & Techniques Flashcards
What is an Initial Therapy Plan based on?
Diagnostic findings and pretreatment baselines
What is an Initial Therapy Plan?
A plan developed at the beginning of treatment
It specifies short term objectives and long term goals
What are the six parts to an Initial Therapy Plan?
Identifying information
Background/History
Goals & Objectives
Reinforcement
Family Involvement
Generalization Plan
What are Progress Notes?
Short reports written during or after each session
What three benefits do Progress Reports provide?
Enable to clinician to monitor the treatment plan
Provide information to other professionals on the treatment team
Facilitate the continuity of treatment should another clinician need to provide services
What are the four basic parts to a progress report?
Subjective
Objective
Assessment
Plan
What are Progress/Final Reports?
Written at specific intervals throughout treatment and at the termination of treatment
What four things are contained in Progress/Final Reports?
Identifying information
Background Information/Statement of Problem
Therapy Objectives & Progress
Summary/Additional Information
What is in the Subjective portion of a progress report?
Your opinion about client status
What is in the Objective portion of a progress report?
Data collected during session
What is in the Assessment portion of a progress report?
Interpreting data & comparing to previous levels
What is in the Plan portion of a progress report?
Proposed therapy targets for next session
