Progress Notes

Why do we write progress notes?

• Because I am told to

• To engage client in services

• So the agency is paid for services I provide

Which thing should you DO in progress notes?

• Be concise and objective

• Go into great detail

• Use another client's name

• Be concise and subjective

Which word is NOT a group keyword?

• Assisting

• Redirecting

• Practicing

• Encouraging

I should use the terms recess, pool, and movie in my progress notes.

• True

• False

I should use community outing and reflection time in my progress notes.

• True

• False

Medical necessity is the client's diagnosis.

• True

• False

Which one is NOT a good example of medical necessity?

• poor mood management

• major depressive disorder

• self-harmful behaviors

• poor social skills

Which is NOT a good example of current report of functioning?

• Client reported no changes.

• Client reported they won their softball game last night.

• Client reported they didn't sleep well last night.

You should ALWAYS mark AC present in your progress note.

• True

• False

I should try to use quotes in my progress notes, when relevant.

• True

• False