This article provides samples of clinical documentation that you can use as a reference point to complete high-quality, compliant documentation in your own practice. In this article you will find samples of:
- Initial Assessments
- Progress/SOAP Notes
- Treatment Plans
- Safety Plan
- Discharge Note
- Clinical Care Review Update Notes
- Blank Note Templates
Please note: these are just samples and are not intended to be prescriptive of how you must document at Rula; rather these samples simply serve as a reference point to help generate some ideas and considerations for how you can effectively document care in your practice.
Initial Assessments
- Initial Assessment: Adult
- Initial Assessment: Child/Adolescent
- Initial Assessment: Couple
- Initial Assessment: Family
Progress Notes
- Progress Note: Adult
- Progress Note: Child/Adolescent
- Progress Note: Couple
- Progress Note: Crisis Intervention
- Progress Note: Family
SOAP Notes
Treatment Plans
- Treatment Plan: Adult
- Treatment Plan: Child/Adolescent
- Treatment Plan: Couple
- Treatment Plan: Family
Safety Plan
Discharge Note
Clinical Care Review
Blank Note Templates
- Blank Discharge Note
- Blank Initial Assessment - Adult
- Blank Initial Assessment - Child/Adolescent
- Blank Initial Assessment - Couple
- Blank Initial Assessment - Family
- Blank Progress Note
- Blank Safety Plan
- Blank SOAP Note
- Blank Treatment Plan
Updated