When you decide to seek clinical consultation, there are 5 things that you should document in your clinical notes. They are the 5 W's:
When you seek consultation;
Why you are seeking consultation and why now;
Who you are seeking consultation from;
What opinions / information / recommendations {...}
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Records & Documentation
How To Take Clinical Notes Using Gillman HIPAA Progress Notes
This is the fifth post in a series that highlights standardized formats for your clinical notes. The series began here.
I have only recently stumbled across the Gillman HIPAA Progress Note. Of the four methods that I have mentioned, this is the only one that has been developed after the {...}
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How To Take Clinical Notes Using BASIC SID
This is the fourth post in a series that highlights standardized formats for your clinical notes. The series began here.
A third format for clinical note taking is commonly known as BASIC SID. This is yet another mnemonic. The letters stand for Behavior, Affect, Sensation, Imagery, Cognition, {...}
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How To Take Clinical Notes Using DA(R)P
This is the third post in a series that highlights standardized formats for your clinical notes. The series began here.
A second format for documenting your clinical work is called DA(R)P notes, sometimes referred to as DAP notes. These are similar to clinical SOAP notes.
DA(R)P is a {...}
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