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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


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




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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