Documentation
Standards
nProgress
Notes Content
Client encounters,
including relevant clinical decisions and interventions. Descriptions of:
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.