Reference no: EM133190541

Assignment: B.I.R.P. Progress Note Checklist- Progress Notes of a Social Worker Paper

1. Behavior

Counselor observation, client statements

• Subjective data about the client-what are the clients observations, thoughts, direct quotes?
• Objective data about the client-what does the counselor observe during the session (affect, mood, appearance)?

2. Intervention

Counselor's methods used to address goals and objectives, observations, client statements

• What goals and objectives were addressed this session?
• Was homework reviewed?

3. Response

Client's response to the intervention, progress made toward Tx Plan goals and objectives

• What is the client's current response to the clinician's intervention in the session?
• Client's progress attending to goals and objectives outside of the session?

4. Plan

Document what is going to happen next

• What in the Tx Plan needs revision?
• What is the clinician going to do next?
• What is the next session date?

General Checklist

• Does the note connect to the client's individualized treatment plan?
• Are client strengths/limitations in achieving goals noted and considered?
• Is the note dated, signed and legible?
• Is the client name and/or identifier included on each page?
• Has referral and collateral information been documented?
• Does the note reflect changes in client status (eg. GAF, measures of functioning)?
• Are all abbreviations standardized and consistent?
• Did counselor/supervisor sign note?
• Would someone not familiar with this case be able to read this note and understand exactly what has occurred in treatment?
• Are any non-routine calls, missed sessions, or professional consultations regarding this case documented?