Clinical documentation

A question heard frequently in private practice is how do we stay on top of paperwork when our passion is engaging the client in doing meaningful work? What if clinical documentation supports them in getting additional resources such as disability or explores reunification with their children? When

Creative Social Worker : Photo

Feeling stuck during psychotherapy sessions? Here is a list of some common words clinicians use in psychotherapy sessions and documentation. This is a reference guide of over eighty common terminology Therapist can utilized to support documentation and build clinical vocbulary.

Clinical card how is your clinical judgment? effective noticing focused and subjective data recognizing deviations from the expected pattern (cues) seek

The Five Hallmarks of Best-in-Class Clinical Documentation Improvement Programs

Table 2-1: Documentation: Descriptive Words ... - Child Life Read more about herold, ogren, spontaneous, descriptive, seeks and wordsruth.

History & Physical Chief Complaint – Be clear about which complaint (if there are multiple) is the reason for inpatient hospitalization Chronic conditions don’t usually require hospitalization unless the condition is exacerbated – Document the risk associated with not treating the chief complaint in the inpatient hospital setting Concern for specific complications/adverse outcome The likelihood of an adverse outcome if not treated in the inpatient setting