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writing in clinical case notes

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What should be included in progress notes and what should not be included? How confidential are such progress notes in the current managed care world? Describe how much detail should a therapist/counsel include their documentation, for example, should a therapist or counselor include their working hypotheses in their clinical notes?

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There are two things that you need to be mindful of when thinking about writing in clinical case notes:

1. The case notes are likely to be available and read by a wide range of professionals
2. The notes can be read by the patient (usually the patient will have to apply for permission to be able to read them)

You should keep these two points in mind when writing ...

Solution Summary

Tips for writing clinical case notes are demonstrated in this solution.