Depending on the population served and the setting in which you work, what does your agency require for documentation?
Choose a role that you take on as a professional and identify a “measure” that would allow you to assess your skills and continuing professional development needs for that role. This can be an informal measure or a listing from a text book or other resource that describes necessary skills for a particular role. A formal measure may be modified to help you assess your skill. Make reference to this measure as you address the discussion topic. Reading:
In Baird, B. N. (2011). The Internship, practicum, and field placement handbook A guide to the helping professions. (6th Ed.) New Jersey: Pearson Prentice Hall.
Chapter 6: Clinical Writing, Treatment records, and Case notes.
Clay, R. (2007). Keeping Track: New professionals need to know how to keep, safeguard, and destroy records GradPSYCH, 5 (1). http://www.apa.org/gradpsych/2007/01/track.aspx
http://www.apa.org/practice/guidelines/index.aspx. Links to APA guidelines relevant to practitioners, including the APA Record Keeping Guidelines.
This week we will explore the topic of documentation. What are the purposes of documenting our contacts and interactions with clients?
First Term Practicum Students: (CHOOSE ONE)
What should be included in our progress notes and what should not be included? How confidential are such progress notes in the current managed care world? Describe the extent of documentation that is comfortable for you, for example, do you include your working hypotheses in your clinical notes? What other issues come to mind as you think about documentation? Depending on the population served and the setting in which you work, what does your agency require for documentation?
It is ethically incumbent upon the professional that the data they gather be used for its intended purpose(s). In many settings, once those data are part of the record, others may interpret the data and make decisions that may not conform to the original professional’s intent, and those decisions may or may not be in the client’s best interest. What are some strategies that will allow one protect the data they gather?”