Documentation Ideas
PROGRESS- GOALS
-Progress: no/ minor/ significant
-Presenting problems/topics brought by the patient.
OBJECTIVE/ SUBJECTIVE
-Client's behavior (eye contact, body posture,
defiance, aggression, and noncompliance).
-Themes and patterns of what the client
shared and did.
INTERVENTION USED/ PLAN
- intervention - techniques and
strategies used, skills taught
- Homework/ recommendation given.
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