RECORDING

WHAT IS IN A RECORD?

1. Date

2. Basic information about client (age, gender, income, marital status, occupation, etc.)

3. Reason client came in to see you

4. More detailed information about client’s problem

5. Aspects of the intervention process:1.Assessment2.Plan of action3.Progress made4.Recommendations

6. Follow-up information

SOCIAL HISTORY

1. General information

2. Family of origin

3. Marital/relationship history

4. Education history

5. Employment history

6. Social life and leisure activities

7. Nationality/ethnicity/racial identity

SOCIAL HISTORY

8. Religious/spiritual background

9. Current living arrangements

10. Legal background

11. Medical history

12. Emotional status

13. Financial information

14. Recommendations and treatment plan

MEDICAL RECORDING FORMAT

S Subjective information

O Objective information

A Assessment

P Plans

D Data

A Assessment

P Plans

S Mrs. Jones is fearful of returning home after surgery. She wants to be at home, however, she lives alone. She will not consider a nursing home even temporarily.

O Mrs. Jones has just had hip replacement surgery. She does have family in the area. Her overall health is good. She does live alone.

A Mrs. Jones will need supervision and help with dress changes and taking medications. She may also need help fixing meals as her mobility is limited.

P Family plans to stay with Mrs. Jones during her first week home. Home Health will come in for dressing changes and monitoring medications. Home delivered meals may be an option after family leaves and Mrs. Jones is alone.

PRIVACY PRINCIPLES

ConfidentialityAbridgementAccessAnonymity

PAPERWORK = ACCOUNTABILITY

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