Tjane Health Academy · PRP Counselor Field Toolkit
Documentation Do / Don't Guide
The wording that survives review, side by side with the wording that does not.
Language
| Don't write | Do write |
|---|---|
| Participant was non-compliant. | Participant declined the practice today and asked to reschedule for Thursday. |
| Provided support and encouragement. | Rehearsed the pill-organizer routine tied to evening tea; participant completed it once with cueing, then independently. |
| Participant is unmotivated. | Participant attended 3 of 8 scheduled appointments this month and reported forgetting on work days. |
| Doing better. | Prepared 2 meals this week, up from 0 last week, using the written routine. |
| Discussed medication changes. | Participant reported daytime tiredness; supported her in writing the question for her prescriber appointment on 3/14. |
| Client seemed depressed. | Participant spoke slowly, made little eye contact, and said, "I haven't slept in three days." |
Every note answers six questions
- Which written goal did this serve?
- What did the counselor observably do?
- How did the participant respond, in their words?
- What changed compared with last time?
- What is the barrier, if there is one?
- What happens next, and by when?
Compliance red flags
- Identical wording across participants or across dates
- Service documented that did not occur, or times that do not match
- Clinical language outside rehabilitative scope
- Conclusions with no observable basis
- Late entries without a late-entry notation per policy