Documentation Students must provide a written submission of clinical documentation. Include the following: Brief Social History (3 sections) Presenting Problem: Briefly identify client and the client’s reason for seeking services Background Information: Pertinent background information on the client Impressions and Recommendations: This section always begin by restating presenting problem. Then explain clinical impressions of client. Impressions should be supported with statements of observation or direct communication from client. Clinically state recommendations for client based on what your agency offers. No “I” statements. II. Treatment Plan Use the format below. Write clear and measurable goals with at least 2 objectives, include time frames or dates Goal 1: Client will ____ by this date as evidence by… Objective 1: Client will ____ daily/weekly/monthly/date Objective 2: Client will ____ daily/weekly/monthly/date Goal 2: Client will ____ by this date as evidence by… Objective 1: Client will ____ daily/weekly/monthly/date Objective 2: Client will ____ daily/weekly/monthly/date III. Contact Note Write in DAP or SOAP format. Must provide at least 2 examples of case notes in reference to the client. -I HAVE ATTACHED THE PROJECT REQUIREMENTS. -I HAVE ATTACHED THE DISCUSSION BOARD #2 explaining a littlw about my internship -I HAVE ATTACHED THE PROCESS RECORDING PAPER DEALING WITH THE CLIENT. my internship site is TOGETHER WE CAN FOUNDATION.
