It is important for the contract to:
Therapist should reiterate:
Session log
Clinical documentation meats two primary purposes:
2. compliance
Compliance
Progress notes include:
- other observations relevant to progress for the permanent record
Clinical notes
- based on observed data and offer a succinct statement of progress or changes in behaviour
APIE Progress Notes
Assessment
Plan (goals and objectives that were focus of the session)
Intervention
Evaluation (progress in meeting goals)
DART Progress Notes
Description of client and situation
Assessment of current situation
Response of client and therapist
Treatment plan or implementation
SOAP Progress Notes
Subjective: clinical impression of person’s presentation
Objective: Present condition as observed or measured
Assessment: observations of progress in the session
Plan: goals and objectives
Supervision may entail
Transference
When client projects relationships with key figures in life directly to the therapist
Counter-transference
Therapist’s projection of feelings and behaviours toward others onto the client
Phenomenological approach
Study of subjective reality and direct personal experience