Definition of Documentation
There is a wide variety of data related to the treatment process, assessment of the condition of the patient, progress records, plans, and reports. Such data is directly related to the client’s well-being and should be appropriately analyzed. In order to conduct an efficient, timely analysis of these valuable databases, a systematic approach should be implemented. Documentation is a systemized material containing the above-mentioned information, which is recorded according to a particular framework. There is a competency-based approach to documentation, which may contribute to the precise and concise recording of valuable patient-related data.
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Competency 112 implies that documentation should be recorded in relation to treatment goals and objectives. In order to provide appropriate documentation, it is necessary to have sufficient knowledge regarding the process of reviewing and updating records. It is also crucial to know specific clinical terminology and utilize it in documentation in order to achieve treatment goals. Compliance with clinical terminology contributes to the precise interpretation of documentation. It is necessary to have sufficient skills in using standardized abbreviations in order to avoid confusion. The ability to note limitations related to the client and the implemented treatment is significant, as it may help to provide suitable methods and approaches.
Recording changes in the client’s status, behavior, and level of functioning are needed to analyze progress and adjust treatment to achieve objectives. Documentation should also be precise to serve its primary purpose properly. Therefore it is essential to have the ability to prepare clear and legible documents. There are also two considerable attitudes, which should be implemented. It is vital to acknowledge the required objectivity and precision in documentation, as it plays a significant role in treatment provision. There may be rapid changes in the client’s state, hence documentation should be provided in time.