documentation Flashcards
flat affect
no expression
broad affect
wide range of expression
blunted
little, very slow range of emotion
inappropriate
range, but inconsistent and inappropriate
restricted
one type of expression
SOAPIER progress note
Subjected data: gathered from client
Objective data: based on observation and other sources
Assessment: conclusions based on data review
Plan: plan believed to resolve the problem
Interventions
Evaluation: patient’s response to intervention
Revision: changes made from the original treatment plan
DARP note
Data–subjective/objective info supporting the stated focus or describing observations at the time of significant events
Action: a description of the actions taken by the therapist in the form of interventions or programs
Response–a description of the client’s response to the intervention. Client goals and outcomes included
Plan–next interventions to be implemented
intra-individual
action taking place withing the mind or an action involving the mind, but not requiring contact with another person or external object
extra-individual
action directed by a person toward an object in the environment requiring no contact with another person
aggregate
an action directed by a person toward an object in the environment while in the company of other people who are also directing action toward objects in the environment. no action between participants necessary.
inter-individual
action of a competitive nature directed by one person toward another
unilateral
action of a competitive nature among three or more persons, one of whom is “it”.
multilateral
action of competitive nature among three or more persons with no one person as “it”
intragroup
action of cooperative nature by two or more persons intent upon reaching a mutual goal. action requires positive verbal and nonverbal interaction
intergroup
action of a competitive nature between two or more intra groups
