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AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD AUTHORIZATION FOR AUTOPSY In the event authorization for autopsy is obtained by letter, telegram, voice recorded or monitored telephone call, paragraphs

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Hi this is Dr. Diane gay hart and welcome to my lecture on progress notes that goes with my textbook mastering competencies in family therapy the second edition in this lecture I'm going to talk about how to write progress notes, and you will find that these are one of the most common clinical dot forms of documentation and as you work in the field as a therapist or counselor you will be completing several of these each day, so hopefully this lecture will get you started, so progress notes are the document that you complete every day after seeing a client and a typical session and what happens in this document is you basically it is the official record of what happened and what you did so the one hand the most basic reason for doing progress notes is for you to keep a record of what you're doing from week to kind of track your sessions and care, so that's the most basic what purpose of a progress note and in the larger sense there's a there's an ethical and professional standard for maintaining these and because it is the only real documentation we have it's a field where we set a room, and we talk to people, and then you know it's based on our word what we did, and so we use these progress notes to document what happened and so these are very important for third party payers to keep track of what happens if there's ever questions about what happened in session and similarly and progress notes can be helpful in protecting against lawsuits or complaints because they document what we did and so these are generally considered protection or can be protection in those types of situations and so generally it's important to also notice under the new HIPAA regulations like as hip isn't that new it's 2004 I believe um but in that way back then in 2004 and there was a distinction has been made between progress notes and psychotherapy notes, so progress notes are the like official medical record that can be shared with other medical professionals, and it generally has a little more limited scope in the sense that there are certain things that are supposed to go into a HIPAA based progress down go into that in just a minute, but it basically is documenting the symptoms a client had and what you did about that and that's the main thing that progress notes does and as the name indicates you're tracking progress on the other hand psychotherapy notes are separate and from progress notes and these are more for the clinician in terms of thinking through case conceptualizing and putting their thoughts onto paper psychotherapy notes if they are kept in a distinct and separate place and file can be kept separate from the official medical records so for example when you know that a physician is requisitioning or requesting a copy of Records you would generally just send the progress notes where psychotherapy notes are often have basically more subjective impressions of the clinician has and so these are protected a bit more, and it's really more on rare circumstances...

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