Session Charting

Question 1

two documentation systems

Answer 1

wellness charting - general relaxation session with no symptoms/client complaints

SOAPR charting - intention of session is to change/improve symptom/client complaint

Question 2

why chart your session?

Answer 2

SAFETY - ensures safe and effective tx

PROFESSIONALISM - we are healthcare professionals

COMMUNICATION - with other healthcare providers

PROTECTION AND PROOF - proof of care and progress

Question 3

charting guidlines

Answer 3

include date and your signature

no blank spaces should be left

all entries written legibly in ink or typed

record info as soon as possible

use abbreviations sparingly and only those that have been approved

quote clients directly or restate what client said

Question 4

charting erros

Answer 4

should be corrected to allow readers to see and understand the error

a single line through error

insert correct info

correction initialed by person correcting the error

Question 5

wellness charting

Answer 5

simplifies paperwork when appropriate

system to document “healthy” client sessions

contains 3 parts: hx, tx, cx

Question 6

When to use wellness charting

Answer 6

client is healthy, no specific issue to address

client has specific symptom but does not which to address them

spas/hotels/resorts

session intention includes general therapeutic goals: relaxation or improved sense of well-being

Question 7

Hx includes

Answer 7

medications, accidents, surgeries, conditions

Question 8

tx includes

Answer 8

clients goals for session

1-10 rating scale (stress, anxiety, tension)

session length

techniques uzed