Clinical Documentation

In session 9B we learned about the basics of clinical documentation. The who, what, when, where, and why of clinical documentation guides you in the direction of creating a complete and thorough evaluation. This discussion led us to our discussion of SOAP notes which is an acronym for subjective (what they client says), objective (what the therapist observes), assessments (interpretation of the assessment), and plan (what intervention will be chosen for client). As therapist we will use soap notes in almost any setting we work in and it's important for many reasons to have a detailed soap note to help guide other therapist that may work with the client and for insurance purposes. If it wasn't documented it didn't happen.

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