Documentation Standards
nProgress Notes Content
nClient encounters, including relevant clinical decisions and interventions. Descriptions of:
n
nMental Health Symptoms
nTreatment interventions. For example, progress or attempts at progress by both the client and service staff (forward the established personal milestones or other relevant treatment objectives).
nResponses reflective of the Treatment Plan problem, goals and objectives.
nServices related to the diagnosis, signs and symptoms established goals, and expressed in terms of changes in the individual’s functioning. If there is little progress, a clear explanation of the limited progress must be included. Follow-up care.