Clinical documentation

Clinical documentation

The individualized treatment plan sheet has the details of action plan that will be adopted to achieve the desired goals and objectives. The given sheet has few errors as per the guidelines given for good clinical writing. It has some spelling mistakes, which are simple but is a matter of concern when it comes to professional documentation. Some places, overwriting was there making the document less legible. Usage of abbreviated forms which are not accepted universally creates unnecessary trouble in interpretation. Some words were not legible making it difficult to get the meaning. Incorrect use of capitalization was also observed. These were the simple grammatical errors. Apart from that some conceptual lacuna was also found. The client came with a problem of depression due to phobia of public school. The mentioned goals and objectives, though will address the issue but in an indirect way. No mention of direct therapy was included that would be used to addressed the depression issue.

The means by which these areas could be improved are to be carefully designed and appropriate working strategy must be adopted. Being more patient while writing and allowing the thoughts to sink would work incredibly well. This will help in choosing right words for expression. A passion to express clearly must be cultivated. Usage of non standard abbreviations must be avoided in ordinary writing also because it is because of this unconscious habit that one uses same kind of non standard abbreviations in professional documents. Finally the best could be brought out when domain knowledge is enhanced, so constant efforts to improve domain knowledge would pay in a long run.

As a final word, if one develops the right attitude for clinical documentation i.e., to have in the mind the purpose of unambiguous communication of a person’s state of health and treatment plan and if the very essence of serving people is cultivated, then perfection in clinical writing becomes one’s second nature.

Reference

Lichtenberger, E. O., Mather, N., Kaufamn, N. L., & Kaufman, A. S. (2004).Essentials of          assessment report writing. Hoboken, NJ: Wiley & Sons.



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