Clinical documentation is a standard requirement for all treatment settings.  It is needed to reflect medical necessity of ongoing care as well as to provide a roadmap of the individuals course in treatment. Although professionals can verbally reflect what has taken place in a session or the recommended course of treatment; many struggles with how to document in a manner that accurately communicates their assessments.  In addition, documentation often becomes standardized and specific to the treatment setting.   This can unintentionally lead to generalized progress notes and treatment planning.

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