Psychosocial Documentation

ABSTRACT

Effective goals and objectives express the practitioner's knowledge of: (1) their practice area, (2) the specific client, and (3) the client's needs from their own perspective. Through documentation, practitioners demonstrate the clinical reasoning process. Goals and objectives commit one's intentions for intervention explicitly in writing. Their simplicity disguises the skill required to achieve clarity and articulate the process and outcome desired. This paper critiques the skill of writing objectives (short-term goals) in mental health practice, and discusses the need for precise documentation in the context of the crisis confronting occupational therapy in this arena.