Documentation

1. Documentation Renisha Fontenot Presented at MRPA 2010

2. Group Processing & Documentation • WHAT? • Processing: What did we just do? • Documentation: Exactly what was done and talked about within the group. (Activity outline, directions, discussions, etc.) • SO WHAT? • Processing: So what can you take from this activity. • Documentation: So what did think about the client as a result of participation? (affect, attitude, willingness to engage or participate, etc.) • NOW WHAT? • Processing: What can they take from the activity and apply to their personal lives? • Documentation: What do they do with what they just learned and what was just done?

3. DAP NOTES • “D”- Data • Subjective and objective data about patient • Subjective- What client can say or feel • Objective- Observed behavior by therapist • Description of both the content and process of the session • Progress on presented problem This is the WHAT

4. “A” Assessment • “A”- Assessment • Intervention assessment-what’s going on? • Working hypothesis, gut hunches • “Appears to be improving on her assertiveness skills” This is the SO WHAT

5. “P” Plan • “P”- Plan • Response or Revision • What you’re going to do about it. • Next session date • Any topics to be covered in the next session This is the NOW WHAT

6. Hear Me Out DAP Note • D: Patient and peers attended RT group on social skills training in reference to listening skills. Patient started out the group with a discussion about the difference between hearing and listening. Patients participated in Pass It Down. Afterward, they were explained that hearing is the act of perceiving sound as opposed to listening which is consciously taking in information that is given. Patients gave personal experiences when they felt as if they were not being heard and when they wished they would have listened to something that was told to them. Patients were asked to share with the group their personal barriers to listening. Patients then participated in an activity called Hear Me Out. Patients were challenged to just listen to their peer’s responses to questions without responding in any way to what they said. Following the activity, patients were given a worksheet and were told to list two questions that were asked, the two responses that were given, and which peers gave the answer. Patient shared his answers with the group to see how well he listened. Patients then processed the activity to determine how well he and his peers listened to each other, and how difficult it was to just listen without responding. Patients were asked to share their personal barriers to listening during the exercise. Patients were then given a handout on listening habits and listening skills. The group discussed whether they could relate to anything outlined in the handout. Patient and his peers then participated in the Last Word activity. • A: Patient was engaged in activity and appeared to be very open and honest in his responses to questions asked of him. He did well with being able to listen without giving a response.Patient seems to understand how his inability to listen has impacted him being open to changing his . • P: Patient will continue to identify personal barriers to listening and will state three active listening skills that he can use to better communicate within his community of peers and in his personal relationships.

7. Quick Draw DAP Note • D: Patient attended RT session on goal setting and self awareness. Patients were asked to share one bad habit with the group and one previous bad habit that they gave up. Patient shared with peers. Patient was then given a leisure skills activity called Quick Draw. Patient and peers were given directions on how to complete the activity. RT explained that the activity would be a group effort and that it would be timed. When patient and peers completed the first round, they discussed what patterns they found and ways of improving their scores. Patients played a second and a third round and compared their scores. Patients saw a significant improvement in their scores with each round. After the completion of Quick Draw counselor debriefed the group on their problem solving skills and their ability to work together. Patients talked about negative habitual behaviors and learning from past experiences. Patients shared how negative choices have affected their inability to stay sober. Patient then completed a Times 'A Changing worksheet where she was asked to list past leisure activities and was told to indicate which activities involved drugs or alcohol. Patients discussed as a group ways of not falling into the same habits, while still participating in enjoyable activities while maintaining sobriety. • A: Patient appears to understand the negative effects that using has had on her leisure lifestyle. She seems motivated to develop leisure skills that are more conducive to her recovery. • P: Patient will continue to evaluate negative habits and behaviors in order to make necessary changes for a better quality of life and a chance at staying sober. Patient will identify three trigger to using during her leisure time.