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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.

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Clinical Writing/ Records

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  1. Clinical Writing/ Records Presentation By: Ben Curll

  2. 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 

  3. Good Clinical Writing • understandability/clarity • definite,specific, concrete language • simplify writing, not the client • revise your writing

  4. Common Writing Problems • clarity • choice of wording • grammar • transition between topics • organization 

  5.             HOW TO IMPROVE CLINICAL WRITING • spelling  • grammar  • content •  feedback •  constructive criticism

  6. REWRITING • find flaws in your writing, try again • technique • develop good writing skills  • practice them 

  7. what not to put in records     • confidential items • personal emotional reactions • unnecessary speculation

  8. SOAP NOTES • used in problem oriented medical records • 4 components •  subjective • objective • assessment • plan 

  9. DART Notes • Description: who, what, where, when, what • Assessment: significance of event • Response: respond to their actions • Treatment: choose treatment relative to condition

  10. Using your Notes • review notes between sessions • address any "homework"

  11. Sign Your Notes • make it legible • print name above signiture • see how supervisor wants you to sign notes 

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