100 common intervention terms used in clinical documentation pdf

DOCUMENTATION/ PAPERWORK

I will be honest. I always have difficulty with this one. With the experience of working at different agencies, I would say I am not 100 percent expert but was able to be better at writing my notes. Each and every agency have its own way of documenting notes. But these are my favorite way of doing it.

TREATMENT PLAN- My favorite find

Whoever created this pdf, they are a godsend for me. Luckily, after I created this website. I received an email via LinkedIn from the creator Kimberly Fore. She created this cheat sheet for the therapists she supervised. She also said she is happy that it has been helpful and also welcomed me sharing it with you guys. This 11-page pdf has specific examples of goals, objectives, and interventions for different topics (abuse/ neglect, addiction, adoption, anger, anxiety, behavior problems,…..and the list goes on). I lost my pdf after I left one of the jobs, and am so glad I found it again. https://studylib.net/doc/7892034/treatment-plan-goals-and-objectives

100 common intervention terms used in clinical documentation pdf

PROGRESS NOTES

Usually, I am famous for writing too much. However, these are the bullet points I usually focus on.

    1. Progress on goals: This is straightforward. Since the last session, how did the patient do? Were they able to achieve the goal/ did worse?
    2. Engagement: This is where I write the patient’s engagement. Usually, it is super easy to write up “Patient was engaged and involved in the session”. or “Patient was refusing to participate, defiant, disrespectful, noncompliant, or aggressive”.
    3. Interventions used by the provider: I just make it basic giving little detail on the interventions “improve or teaching skills”, “explore and process”, and specific modalities “CBT, DBT, play therapy, family therapy….”.
    4. Reactions/ Interactions by the patient: I am not even sure if I should be giving recommendations on this one. I give too many details myself. Hehehe. But I use this one to remind myself of any basic bullet points that I can use later in the sessions”their stress, triggers, belief system, and their reaction to homework given/ interventions suggested”.
100 common intervention terms used in clinical documentation pdf

SOAP Notes

positivepsychology.com has a pdf that you can use to write your notes. It uses S= Subjective, O= Objective, A= Assessment, and P= plan. You can find the pdf and also read more on how to write notes. https://positivepsychology.com/soap-notes-counseling/

100 common intervention terms used in clinical documentation pdf

INTERVENTION TERMINOLOGY

I am not sure if you have seen this one online. But this one is a famous one too. It lists common intervention terminology in the documentation. I am not sure who created this. But these words help a lot when I am writing my documentation. https://www.pinterest.com/pin/534169205775458559/

100 common intervention terms used in clinical documentation pdf

SAID SYNONYM

I don’t know about you. But I also have a very difficult time finding other words than said, when I am doing my paperwork. If that’s you. Here is a list of words you can use other than said.

100 common intervention terms used in clinical documentation pdf

What are examples of interventions in therapy?

In order to help spread good therapy practice, this article lists popular therapy interventions, must-have skills, and techniques that you can use in your practice..
Dance/ Movement Therapy. ... .
Laughter Therapy. ... .
Drama Therapy. ... .
Hypnotherapy. ... .
Music Therapy..

What are treatment plan interventions?

Interventions are what you do to help the patient complete the objective. Interventions also are measurable and objective. There should be at least one intervention for every objective. If the patient does not complete the objective, then new interventions should be added to the plan.

What does Sirp note mean?

Security Incident Response Plan (SIRP)

What should be included in progress notes therapy?

In general, all progress notes should include the following:.
Demographic/identifying information..
Description of your client's behavior..
Treatment plans going forward..