Documentation Standards
nProgress Notes Content
nResponse
nWhat is the client’s response to your counseling/intervention?
nThe result may be good or bad. How did the client respond?
nDiscuss any need for follow-up or client monitoring if follow-up is necessary. Write it in the Progress Notes and make sure follow-up happens. nMake sure ALL follow-up work is also charted and reference the Progress Note (date, type of Progress Note, and the referring staff person.
nDiscuss issues of concern or significance.