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THE PROGRESS NOTE THE PROGRESS NOTE
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]
Sample SOAP Note  ,[object Object]
Sample SOAP Note  ,[object Object]
Sample SOAP Note  ,[object Object]
Sample SOAP Note  ,[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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Progess Note Presentation2

  • 1. THE PROGRESS NOTE THE PROGRESS NOTE
  • 2.
  • 3. Think of the Note as a: • Legal • Clinical • Insurance document • A document the patient has access to.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11.
  • 12.
  • 13. 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
  • 14.