Most Googled Therapy Progress Notes Questions

[@debbiesmith7212]

What information should and should not go in a medical record when you provide counseling in a cancer center.

[@MaelisaMcCaffrey]

That really depends on the clinic's format. In most medical settings, the therapy progress notes are part of the general medical record and it's meant for continuity of care and treatment planning among the team. I would make sure your client is aware that you take notes and ask if they'd like to see them. This is an example where something like "history of sexual abuse" would be very relevant, but you may not want to include details beyond that.

[@shimongendelman1497]

When is your next sale on your Private Practice Coarse?

[@MaelisaMcCaffrey]

The Private Practice Paperwork Crash Course is always free!

[@sammieb9009]

@@MaelisaMcCaffreythank you. I love watching you as most don’t go over the aspects you cover I. Your videos and it puts someone like myself at ease knowing it. Thank you so much.

[@maribelflores6470]

If they’re crying, just put crying spells for symptom and/or intervention used for crying spells

[@MaelisaMcCaffrey]

I would actually just recommend "client cried" because "crying spells" may be interpreted as a judgement and indicates it's a more continuous behavior.

[@wendyleeconnelly2939]

I usually write "tearful" as in "client was tearful" "client was tearful at moments" "client was tearful throughout"

[@videt7459]

@@wendyleeconnelly2939 This. I also always include 'congruent with content' after 'client was tearful at times/throughout' just to make clear that it's not lability or other abnormal crying