Documentation
Standards
Progress Notes Content
Response
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.