Contact Sheet

Making Entries on the Contact Sheet

"Landmarks" in managing the client's interactions at the Clinic are logged on the Contact Sheet in the third section of the client's file. The Contact Sheet serves as a resource for Clinic staff to quickly view pertinent information about the client's care. A staff member should be able to look at the contact sheet and determine the client's current status and a record of events that were perpetrated in the interest of serving the client's needs.

"Landmarks" include events such as the following:

The date that therapy began for the semester and how frequently it was scheduled.
When another professional was contacted to discuss aspects of the client's case.
Notes pertaining to changes in the client's status, such as change of clinician or health status.
The date therapy ended for the semester and recommendations for the future.
Referral to another professional

As your client's clinician, you are responsible for logging event in the client's chart. It is best to log entries right away, as it might be easy to forget to do so later. Be sure to date each entry and specify your name as the clinician on the Contact Sheet as well. Your Clinical Instructor will check the file periodically; it will be reviewed with you at the end of the semester to insure all entries have been completed.