chapter  13
Documenting the Session
Necessary Evil or Clinical Tool?
ByButch Losey
Pages 14

The complete client chart serves many different functions for quite a few different entities. F. G. Reamer dentified that the clinical chart serves six primary functions. These functions serve to increase quality of care, provide interdisciplinary communication and coordination, support the supervision and development of the clinician, and protect the clinician and supervisor from liability. A carefully written session note will improve and enhance the treatment process by helping the clinician track the couple's progress in treatment and help them stay focused on the treatment plan. This chapter suggests that the session note be content-driven and include three primary sections: description, intervention, and response and treatment planning. The couple's response to intervention should be documented in the session note following the discussion of the intervention. Collaborative documentation, sometimes referred to as "concurrent documentation," is a process in which clinicians and clients collaborate in the documentation, assessment, service plan, and session note.