When documenting for self-protection
a. documentation should be relatively vague so as not to reveal too much information.
b. as much detail as possible (e.g., dates, times of events, and exact words spoken) should be included.
c. in the event a counselor realizes that documentation should have been occurring sooner, the counselor should back-date the documentation rather than write a summary of what has happened up to that point in time.
d. counselors document to avoid responsibility for clinical decisions that were made or actions that were taken.
e. counselors should avoid including information related to disagreements they have had with a client.
Question 2
Gianni was having difficulty in his relationship with his wife Anna. To identify Gianni's focal concern, a brief psychodynamic therapist would be most likely to ask
(a) What do you want from Anna?
(b) What does Anna want from you?
(c) What goals do you and Anna have for your lives together?
(d) When do you and Anna get along best?
Documenting the health history is a crucial step in providing patient care
Handwritten documentation.
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Descriptors for Documenting Palpation Findings Cont
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