Notes and the clinical record
Writing and signing session notes, countersigning, correcting a signed note, diagnoses, measures and vital signs, and the templates notes and forms are built from.
Articles
- Writing and signing a session noteStart a note against a session, write it under your template's headings, name what the session was about, and sign it.
- Countersigning a supervisee's noteFind the notes waiting on your countersignature and countersign them.
- Correcting a signed note or adding an addendumAdd an addendum to a signed note, or correct it with a new version you sign, leaving the signed version readable.
- Recording a diagnosisAdd a coded diagnosis to a client's problem list, date it, and mark it resolved.
- Recording a measure such as the PHQ-9Give a client an instrument in the room or record one they filled in on paper, and read their scores over time.
- Recording a vital signRecord a blood pressure, heart rate, weight or other reading, with its unit and when it was taken.
- Building note templates, forms and instrumentsTake a copy from the Weft library, fork a standard one, build your own, or bring one in from a spreadsheet.