Unit 5-01: Putting Together the Paperwork Puzzle

Purpose:
Due to limitations of funding and number of treatment sessions, therapists and their clients no longer have the liberty of just talking about what is on the client’s mind during a session, but must move the client through treatment with intention.

This unit is designed to help the clinician in developing problem statements and treatment objectives designed to assist the client in making progress through his or her treatment plan. Though paperwork may seem to be for the therapist, it actually guides the client with intention as treatment objectives are planned and met. This two hour session will move from assessment through diagnostic statements, problem statements and treatment objectives to progress notes, discharge and continuing care plan.

Learning Objectives:
At the end of this session, the participant will be able to:

• Use assessment instruments to write a diagnostic statement.
• Write problem statements that define the client’s “problem.”
• From the “problem” statement(s), write treatment objectives.
• Write progress notes.
• Understand what a continuing care plan includes.

Unit Outline:

• Assessment tools
• Problem statements
• Treatment objectives
• Progress notes
• Continuing care plan/discharge summary