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Clinical Writing/ Records. Presentation By: Ben Curll. What is Clinical Writing anyway?. clinical writing is a form of record keeping for health/ mental health professions used to document client what their current situation is progress of client in therapy . Good Clinical Writing.

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clinical writing records

Clinical Writing/ Records

Presentation By: Ben Curll

slide2

What is Clinical Writing anyway?

  • clinical writing is a form of record keeping for health/ mental health professions
  • used to document client
    • what their current situation is
    • progress of client in therapy 
good clinical writing
Good Clinical Writing
  • understandability/clarity
  • definite,specific, concrete language
  • simplify writing, not the client
  • revise your writing
slide4

Common Writing Problems

    • clarity
    • choice of wording
    • grammar
    • transition between topics
    • organization 
slide5

            HOW TO IMPROVE CLINICAL WRITING

    • spelling 
    • grammar 
    • content
    •  feedback
      •  constructive criticism
slide6

REWRITING

  • find flaws in your writing, try again
  • technique
  • develop good writing skills 
    • practice them 
what not to put in records
what not to put in records    
  • confidential items
  • personal emotional reactions
  • unnecessary speculation
soap notes
SOAP NOTES
  • used in problem oriented medical records
    • 4 components
  •  subjective
  • objective
  • assessment
  • plan 
dart notes
DART Notes
  • Description: who, what, where, when, what
  • Assessment: significance of event
  • Response: respond to their actions
  • Treatment: choose treatment relative to condition
using your notes
Using your Notes
  • review notes between sessions
  • address any "homework"
sign your notes
Sign Your Notes
  • make it legible
    • print name above signiture
  • see how supervisor wants you to sign notes 
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