Progess Note Presentation2

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cctian

On writing a clinical progress note.

Salud y medicina Tecnología

At minimum a PN should say: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Think of the Note as a: • Legal • Clinical • Insurance document • A document the patient has access to.

SOAP ,[object Object],[object Object],[object Object],[object Object]

Subjective ,[object Object],[object Object],[object Object],[object Object],[object Object]

Objective ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Plan ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

The STIPS S igns and Symptoms mood, affect, attention, concentration, demeanor, cognition, quality of speech T opics of Discussion Use direct quotes I nterventions Interpretation Homework P rogress and Plan Client at baseline Client Worse Will continue to monitor S pecial Issues Red Flags: Suicidal Ideation

Important Issues ,[object Object],[object Object],[object Object],[object Object]

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