Client Record information
face sheet, inquiry/referral form, verification letter, Assessment form/social history, release of information forms, service plan, referrals
Documentation, legal and administrative purposes
need documentation or else it didn’t happen
Length of contact notes
never more than 6-7 sentences
Labeling contacts
left margin of case note include: date, type of contact, type of visit
Documentation Best Practices
Avoid hostility, Document interactions, quotes, avoid contradictions, accurately describe disabilities, do not be judgmental
Advocacy
how to properly help the client
Broad goal and specific/impact goal
Objectives