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M2 Discussion: Analyze and Revise Documentation Samples
 
In this module, you've learned the importance of using direct quotes and concrete, non-judgmental, behaviorally descriptive, non-discriminatory and grammatically co
ect language in the case record.
For this discussion you must:
1. Identify what needs to change in each documentation sample to conform to best practice.
2. Revise the samples.
3. Explain how your revisions improved them.
Documentation Samples:
1. Mrs. Smith is a 42 year old alcoholic. It is clear to me that she won't change. She kept giving me dirty looks for the whole session. She seemed to be just going through the motions with me, saying anything she thought I wanted to hear.
2. I met the new client for the first time today. Despite my efforts to engage her, she refused to make eye contact. I think she might be autistic. The interview didn't last long because she gave one word answers to everything I asked her. All I got out of her was her name, date of birth, and social security number.
Answered 3 days After Feb 06, 2024

Solution

Dipali answered on Feb 09 2024
7 Votes
WRITTEN ASSIGNMENT        4
WRITTEN ASSIGNMENT
Table of contents
Introduction    3
Revised Documentation Samples    3
Conclusion    4
References    5
Introduction
Counselors need to ensure that their paperwork is accurate, impartial, and compliant with ethical guidelines. In order to comply with best practices, this topic offers updated documentation samples that place a focus on direct quotes, nonjudgmental language, and behaviorally descriptive observations.
Revised Documentation Samples
· Original: "Mrs. Smith is a 42 year old alcoholic. It is clear to me that she won't change. She kept giving me dirty looks for the whole session. She seemed to be just going through the motions with me, saying anything she thought I wanted to hear."
· Revised: "42-year-old Mrs. Smith comes in with wo
ies about her alcohol consumption. She displayed nonve
al clues during the discussion, such keeping eye contact directly, which might be...
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