You can learn to write effective, clear and professional case notes.
Writing case notes is an important part of clinical practice. In fact, your clinical practice could survive or perish on the quality of your charting.
Charting, the practice of keeping objective documentation describing your clinical interventions, is your only real proof of your clinical actions. If your interventions are ever called into question it will be the quality of your notes that will help describe or defend your assessment and choice of clinical interventions.
“Trust me, I’m a trained professional.” is not a strong legal defense.
There are different types of documentation and proper ways to write notes. How can the beginning clinician decide which charting format is the best one? How do you write an opening note? What is PAIP charting? And what is the proper type and amount of information to include in your clinical documentation?
Click on Types of Case Notes to find out.
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