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.
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.