- 1 Counseling Progress Notes Template to Communicate the Treatment to Your Staff
- 2 How Do You Write a Counseling Note?
- 3 What Should Be Included in a Counseling Progress Notes?
- 4 What Are Actually Progress Notes in Counseling?
- 5 What Should a Psychotherapy Progress Note Include?
- 6 How Long Do You Have to Keep Psychotherapy Notes?
Counseling Progress Notes Template to Communicate the Treatment to Your Staff
Counseling progress notes are the documents or notes on the patient developments. This note is something that’s legal and protected. The purpose of making it is not given to the patients, but to be read to the team of counseling staff to provide care for the patient concerned. The note is made for a certain period when the counseling is carried out. It should be detailed, but not too long and convoluted. Therefore, it is a good idea to use the counseling progress notes template. Now, check out the following information about this note.
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How Do You Write a Counseling Note?
The steps that must be taken in making counseling progress notes are:
- First, you need to list the details. It concerns the patients and their condition. You should be really careful in writing the details. Minimize all forms of mistakes.
- Then, describe the treatment that has been applied. All treatments must be described in an efficient and detailed manner.
- Write down the patient’s progress. You must write the progress of each treatment. Besides the progress, if what you get is setback, you also have to write it properly.
- Make a progress chart. Since the counseling progress notes will be seen by all staff members, the chart functions to see the increase or decrease in overall progress. In this way, a comprehensive conclusion can be drawn.
- Next is related to the way of writing. Write everything clearly.
- Then, it is related to patient privacy. You must keep everything you write as concerned privacy. It should only be shown to members of the official team. If you break this rule, you could be caught in a lawsuit.
What Should Be Included in a Counseling Progress Notes?
Basic information that must be included in a counseling progress notes template are:
- Identity of the patient
- Cause and reason
- Medical history
- Mental health history
- Social history
- Legal involvement
- Mental status
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What Are Actually Progress Notes in Counseling?
This note is actually a diagnosis of patients. It also contains an assessment of symptoms and treatment, as well as the progress. It must follow certain standards, for example the standards from SOAP, BIRP, ARE, and so on.
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What Should a Psychotherapy Progress Note Include?
Psychotherapy progress notes must include the following things:
- Basic records
- Progress notes
- Who did the treatment and what was done
- When is the treatment done
- Release information
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How Long Do You Have to Keep Psychotherapy Notes?
If there are no specific terms and conditions, the records regarding counseling must be kept for seven years for adults, and three years for children.
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Those are the important things as a source of information regarding counseling progress notes template. Provide the best progress notes to help your team giving the best service for your patients.
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