Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation.

Previous edition published with title: STEPnotes the Counselor's Guide to Progress Notes.

Why progress notes are important to counselors -- Clinical language -- The STEPs to taking progress notes -- The first "STEP": S= Subject(s) and symptoms -- The second "STEP": T= Therapeutic tools -- The third "STEP": E= Evaluation -- The fourth "STEP": P= Plan -- STEPnotes for career counselors -- STEPnotes for school counselors -- Paper version of STEPnotes -- Additional clinical documentation -- Glossary of Clinical Terms.