Clinical Documentation

Today we talked more about the importance of documentation and what goes into a successful documentation note. There are 5 segments to documentation which include who, what, when, where, and why, which contain important information about the client and the general therapy session. One segment that was discussed in more detail today was the "what" aspect of documentation. There are many things that fulfill this question such as basic information about the client, information about the assessment and intervention, and also the observation that occurred in the clinic. In addition, we briefly talked about the importance of error correction. It is important to correct documentation errors in a specific way in order to be sure nothing is covered up. If you find an error in a printed document, you must mark through it, correct it, and initial it, without completely scratching through the error.