GEHART CHAPTER 15 - DOCUMENTATION

Question 1

PROGRESS NOTES

Answer 1

GO INTO THE OFFICIAL/FORMAL MEDICAL RECORD THAT IS SHARED WITH OTHER MEDICAL PROFESSIONALS, CLIENTS, AND/OR IN RESPONSE TO SUBPOENAS

Question 2

PSYCHOTHERAPY NOTES

Answer 2

PROPERTY OF THE COUNSELOR AND REMAIN SEPARATE FROM THE FORMAL MEDICAL RECORD (IF THEY ARE KEPT PHYSICALLY SEPARATELY)

• INCLUDE PERSONAL IMPRESSIONS, ANALYSES OF CLIENT, HYPOTHESES, ETC.
• HAVE GREATER PROTECTION UNDER HIPAA AND RARELY, IF EVER, DISCLOSED TO AN OUTSIDE THIRD PARTY.
• PURPOSE IS TO HELP CO THINK THROUGH, PLAN, AND REFLECT ON CL PROGRESS.

Question 3

DAP PROGRESS NOTES

Answer 3

DATA - WHAT HAPPENED IN SESSION, INTERVENTIONS, CLINICAL OBSERVATIONS, TEST RESULTS, SYMPTOM DIAGNOSIS, STRESSORS
ASSESSMENT - ASSESSMENT OF SYMPTOMS, OUTCOME OF CURRENT SESSION, OVERALL COURSE OF THERAPY, TX PLAN GOALS AND OBJECTIVES BEING MET, AREAS NEEDING MORE WORK, AREAS OF PROGRESS
PLAN - HOMEWORK, INTERVENTIONS FOR NEXT SESSIONS, TIMING OF NEXT SESSION, CHANGES TO TX PLAN, P FOR PROGRESS AND EMPHASIZE ANY PROGRESS MADE

Question 4

SOAP PROGRESS NOTES

Answer 4

SUBJECTIVE OBSERVATIONS - DESCRIPTION OF CL’S NARRATIVE AND/OR REPORTED SYMPTOMS
OBJECTIVE OBSERVATIONS - CO’S OBSERVATIONS, TEST RESULTS, FINDING FROM PHYSICAL EXAMINATION, VITAL SIGNS, ETC.
ASSESSMENT - SUMMARY OF SYMPTOMS, ASSESSMENTS, AND DX; DIFFERENTIAL DIAGNOSIS CONSIDERATIONS
PLAN - PLAN TO TREAT LISTED SYMPTOMS, INCLUDING INSTRUCTIONS AND MEDICATIONS GIVEN TO CLIENT.