clinical documentation

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Clinical Clinical DocumentationDocumentation

2006 Annual Texas Institute on2006 Annual Texas Institute onSubstance Abuse and Mental Substance Abuse and Mental

HealthHealth

Rhonda G. Patrick, LCSW Rhonda G. Patrick, LCSW

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Clinical DocumentationClinical Documentation


ASSESSMENTASSESSMENT


What is the assessment?What is the assessment?An ASSESSMENT is the gathering of An ASSESSMENT is the gathering of relevant information about the client, relevant information about the client, their environment, their problem(s), and their environment, their problem(s), and what they hope to accomplish through what they hope to accomplish through the therapeutic intervention.the therapeutic intervention.


Goals of the AssessmentGoals of the AssessmentThe assessment should answer the followingThe assessment should answer the followingquestions:questions:► Is treatment of any kind required?Is treatment of any kind required?►What are the relative merits of the What are the relative merits of the

intervention?intervention?►What types of treatment approaches might be What types of treatment approaches might be

appropriate?appropriate?►What is the depth of therapy needed?What is the depth of therapy needed?►Who should the therapy involve?Who should the therapy involve?►Have cultural issues been considered?Have cultural issues been considered?


Goals of the AssessmentGoals of the Assessment

The Assessment should answer these basicThe Assessment should answer these basicQuestions:Questions:►Why is the client seeking treatment?Why is the client seeking treatment?►How have these problems affected the client’s How have these problems affected the client’s

life?life?►What is maintaining these problems?What is maintaining these problems?►What does the client hope to gain from What does the client hope to gain from

treatment?treatment?


Who can conduct an Assessment?Who can conduct an Assessment? Licensed Counselor (LCDC, LPC, LMSW, Licensed Counselor (LCDC, LPC, LMSW,

Ph.D) Ph.D) Registered Counselor InternRegistered Counselor InternBoth are:Both are:

Knowledgeable to assess the specific needs Knowledgeable to assess the specific needs of the client being servedof the client being served

Are trained in the use of applicable and Are trained in the use of applicable and appropriate toolsappropriate tools

Are culturally sensitive to the client’s needsAre culturally sensitive to the client’s needs


Parts of the Assessment Parts of the Assessment ► Presenting Problem or Chief ComplaintPresenting Problem or Chief Complaint► Alcohol and Other Drug Use History (use)Alcohol and Other Drug Use History (use)► Family and Social/Leisure History (activities)Family and Social/Leisure History (activities)► Educational/Employment History (training)Educational/Employment History (training)► Legal HistoryLegal History►Mental Health History (mental/emotional Mental Health History (mental/emotional

functioning)functioning)►Medical History (HIV, STD, TB, HEP)Medical History (HIV, STD, TB, HEP)► Client Strengths and LimitationsClient Strengths and Limitations► RecommendationsRecommendations


Presenting ProblemPresenting Problem Asks the client:Asks the client:

What brings you here today?What brings you here today?Why do you think you need Why do you think you need

treatment?treatment?


Alcohol and Drug UseAlcohol and Drug Use► Substances used in the pastSubstances used in the past► Substances used recentlySubstances used recently► Frequency/amount/durationFrequency/amount/duration► Route of administrationRoute of administration► Year or Age of first useYear or Age of first use► Behavior related to obtaining substancesBehavior related to obtaining substances► Use or recovering from alcohol or other drugsUse or recovering from alcohol or other drugs► Previous overdose, withdrawal, or adverse Previous overdose, withdrawal, or adverse

drug or alcohol reactionsdrug or alcohol reactions► Attempts to decrease/stop use Attempts to decrease/stop use ► History of previous substance abuse treatment History of previous substance abuse treatment

receivedreceived


Family, Social & LeisureFamily, Social & Leisure The family history should include:The family history should include:

The occupation and education of The occupation and education of patentspatents

The number of siblings and their birth The number of siblings and their birth orderorder

The quality of clients relationship to The quality of clients relationship to parents and or siblingsparents and or siblings

Significant extended family members Significant extended family members Parental approach to child rearingParental approach to child rearingFamilial expectations for the clientFamilial expectations for the client


EducationalEducationalEducational history can give:Educational history can give:

Rough estimate of the client’s level of Rough estimate of the client’s level of intelligence intelligence

Aspirations, goals, ability to gain from learning Aspirations, goals, ability to gain from learning experiences experiences

Willingness to make a commitmentWillingness to make a commitmentAmount of perseverance Amount of perseverance Ability to delay gratificationAbility to delay gratification


EmploymentEmployment Employment history can: Employment history can:

be useful in developing an effective treatment be useful in developing an effective treatment planplan

give insight into the client’s ability to get along give insight into the client’s ability to get along with others and take directionwith others and take direction

show client’s ability for assuming the role of a show client’s ability for assuming the role of a client client

show compliance with treatment show compliance with treatment recommendationsrecommendations


Legal HistoryLegal History Currently legal problems Currently legal problems

probation probation parole parole awaiting trial/sentencing awaiting trial/sentencing recently released from jail/prisonrecently released from jail/prison

Complications with legal situationComplications with legal situationpositive UApositive UA

Are legal problems directly related Are legal problems directly related to substance use?to substance use?


Mental Health HistoryMental Health History Can shed light on whether the current Can shed light on whether the current

problem is part of a single or recurrent problem is part of a single or recurrent episode.episode.

A progression of behavioral health problems A progression of behavioral health problems over a period of time. over a period of time.

What treatment approaches have or have What treatment approaches have or have not worked. not worked.

Client’s willingness to engage in the Client’s willingness to engage in the treatment process.treatment process.

Get an idea of current emotional functioning.Get an idea of current emotional functioning.


Medical HistoryMedical History At a minimum document:At a minimum document:

any significant illnesses any significant illnesses hospitalizations hospitalizations past and current physical illnesses or past and current physical illnesses or

conditions conditions breast or prostate cancerbreast or prostate cancerdiabetesdiabeteshypertensionhypertension

injuries or disorders affecting the central injuries or disorders affecting the central nervous systemnervous system

any functional limitationsany functional limitationsHIV, STD, TB or Hepatitis exposure or contactHIV, STD, TB or Hepatitis exposure or contactcursory family history of significant medical cursory family history of significant medical

problemsproblems


RecommendationsRecommendations The assessment must include:The assessment must include:

The clinical recommendationsThe clinical recommendations counselingcounseling education education treatmenttreatment

Recommendation for treatment must indicate the level of Recommendation for treatment must indicate the level of care care Detox Detox Residential Residential OutpatientOutpatient

► What are the recommended:What are the recommended: services services length of stay length of stay intensity of servicesintensity of services

► Diagnostic Justification SummaryDiagnostic Justification Summary


DSM-IV Multi-axial Diagnostic DSM-IV Multi-axial Diagnostic SystemSystem

►Axis IAxis I (Clinical Disorders, other conditions that may be a (Clinical Disorders, other conditions that may be a focus of attention) Examples: Substance abuse, substance focus of attention) Examples: Substance abuse, substance dependence, anxiety disorders, mood disorders, schizophreniadependence, anxiety disorders, mood disorders, schizophrenia

►Axis IIAxis II (Personality disorders, mental retardation) (Personality disorders, mental retardation) Examples: Borderline personality disorder, antisocial personality Examples: Borderline personality disorder, antisocial personality disorder, avoidant personality disorder, mental retardationdisorder, avoidant personality disorder, mental retardation

►Axis IIIAxis III (General medical conditions) Examples: Cancer, (General medical conditions) Examples: Cancer, Hypertension, Diabetes, Migraines, Chronic Pain, InjuriesHypertension, Diabetes, Migraines, Chronic Pain, Injuries

►Axis IVAxis IV (Psychosocial and environmental problems) (Psychosocial and environmental problems) Examples: Problems with primary support group, occupational Examples: Problems with primary support group, occupational problems, problems relating to social environmentproblems, problems relating to social environment

►Axis VAxis V (Global assessment of functioning) Example: GAF (Global assessment of functioning) Example: GAF ScoreScore


Other IssuesOther Issues►Problem ComplexityProblem Complexity►Readiness to ChangeReadiness to Change►Resistance to ChangeResistance to Change►Social SupportsSocial Supports►Coping StylesCoping Styles►MotivationMotivation


Treatment PlanningTreatment Planning


The purpose of Treatment PlanningThe purpose of Treatment Planning

► To clarify the treatment focusTo clarify the treatment focus► The set realistic expectationsThe set realistic expectations► To establish a standard for measuring To establish a standard for measuring

treatment progresstreatment progress► The facilitate communication among The facilitate communication among

professions (both Clinical and Support)professions (both Clinical and Support)► To support treatment authorizationsTo support treatment authorizations► To document quality assurance effortsTo document quality assurance efforts


Treatment Plan ContentTreatment Plan Content►Problem ListProblem List►Presenting ProblemPresenting Problem►Goals Goals ►ObjectivesObjectives►TreatmentTreatment► InterventionsInterventions►Criteria for DischargeCriteria for Discharge


Treatment Problem FormatTreatment Problem Format


Problem ListProblem List► Problems that are judged by any of the potential Problems that are judged by any of the potential

referring parties to:referring parties to: have a significant impact on the client’s ability to have a significant impact on the client’s ability to

function appropriately and adequately in any sphere of function appropriately and adequately in any sphere of life (e.g., family, social, work, school) life (e.g., family, social, work, school)

be amenable to behavioral health care intervention be amenable to behavioral health care intervention should be listed hereshould be listed here

► The identified problems should be stated in The identified problems should be stated in clear and unambiguous language in the clear and unambiguous language in the treatment plantreatment plan Example:Example:

► ““problems in school” could mean a lot of things for a problems in school” could mean a lot of things for a given client, instead “academic underachievement,” given client, instead “academic underachievement,” “disruptive behavior during class,” for “aggressive “disruptive behavior during class,” for “aggressive behavior outside the classroom” provides a better behavior outside the classroom” provides a better description of the problem that would be the focus of the description of the problem that would be the focus of the treatment.treatment.


Presenting ProblemPresenting Problem► Should contain a statement about the problem Should contain a statement about the problem

for which the client is seeking treatment.for which the client is seeking treatment.► Clarification of how the problem is evidenced for Clarification of how the problem is evidenced for

this this specificspecific client. client. ► Identification of the symptoms that fit DSM-IV Identification of the symptoms that fit DSM-IV

criteria criteria ► Should always be documented in the client’s own Should always be documented in the client’s own

words.words.► The client’s own problem description frequently The client’s own problem description frequently

can:can: convey more information about themselves convey more information about themselves the intensity of the problem the intensity of the problem and how these problems affect their life thenand how these problems affect their life then


Treatment GoalsTreatment Goals►The counselor and client will identify The counselor and client will identify

of treatment goals. of treatment goals. ►Goals can be client-identified or Goals can be client-identified or

third-party goals.third-party goals.► It is important to have clients It is important to have clients

identify what the anticipated or identify what the anticipated or hoped-for results of achieving their hoped-for results of achieving their goals will be.goals will be.


Client-Identified GoalsClient-Identified Goals Ask the client directly what their goals Ask the client directly what their goals

are using these three questions:are using these three questions:1.1. What do you see as our biggest What do you see as our biggest

problem?problem?2.2. What do you want to be different about What do you want to be different about

your life at the end of your treatment?your life at the end of your treatment?3.3. Does this goal involve changing things Does this goal involve changing things

about yourself?about yourself?


Client-Identified Goals, Cont.Client-Identified Goals, Cont.

Does this goal involve changing Does this goal involve changing things about yourself?things about yourself?This question forces the client to think This question forces the client to think through their problems and realize the through their problems and realize the extent to which these problems have control extent to which these problems have control over their thoughts, feelings, and over their thoughts, feelings, and behavior(s). It can provide a means for behavior(s). It can provide a means for clients to gain insight into their problems – a clients to gain insight into their problems – a therapeutic goal in and of itself.therapeutic goal in and of itself.


Client-Identified Goals, Cont.Client-Identified Goals, Cont. Ask clients the following questions Ask clients the following questions

relating to establishing objective relating to establishing objective outcome criteria for goal achievement:outcome criteria for goal achievement:

1.1. How will you know when things are different?How will you know when things are different?2.2. What kinds of things will you be doing What kinds of things will you be doing

differently?differently?3.3. What negative things will no longer be What negative things will no longer be

present?present?4.4. What positive things will you be doing?What positive things will you be doing?

These questions offer clients an opportunity to gain These questions offer clients an opportunity to gain insight into their problems.insight into their problems.

Clinician feedback can help clients see how realistic Clinician feedback can help clients see how realistic their expectations are for treatment and determine their expectations are for treatment and determine whether those expectations should be modified.whether those expectations should be modified.


Treatment goals set by non-client Treatment goals set by non-client stakeholders in the treatment process stakeholders in the treatment process must always be considered, examples:must always be considered, examples:

spousesspouses judicial systemjudicial system employeremployer family membersfamily members

Third party expectations of outcomes should Third party expectations of outcomes should be sought and/or modified based on the be sought and/or modified based on the clinician’s evaluation of how realistic they are.clinician’s evaluation of how realistic they are.

Third Party GoalsThird Party Goals


► The following questions can be used The following questions can be used to determine if they are realistic:to determine if they are realistic:

1.1. Does the client have the motivation Does the client have the motivation to do the work that is required?to do the work that is required?

2.2. Does the client have a support Does the client have a support system to assist them?system to assist them?

The reality of the situation must be taken into The reality of the situation must be taken into consideration when determining whether a specific consideration when determining whether a specific goal, objective, or time frame should become part goal, objective, or time frame should become part of the treatment plan.of the treatment plan.

Treatment Plan ObjectivesTreatment Plan Objectives


► Goals and objectives should be:Goals and objectives should be: stated in measurable termsstated in measurable terms goals and objectives should be quantifiable, goals and objectives should be quantifiable, specific and easily understood by the client and all specific and easily understood by the client and all

stakeholdersstakeholders► Measurability allows for:Measurability allows for:

tracking client progress through the treatment tracking client progress through the treatment processprocess

providing information regarding the effectiveness of providing information regarding the effectiveness of the treatment planthe treatment plan

allows the client to see what they have allows the client to see what they have accomplished through the treatment processaccomplished through the treatment process



►Goals should be stated in the positive Goals should be stated in the positive (e.g., Increase the client’s level of self-(e.g., Increase the client’s level of self-esteem). esteem).

► Statements in the positive reinforce the Statements in the positive reinforce the idea that the client is striving to gain idea that the client is striving to gain something rather than lose something.something rather than lose something.

► It is often difficult to attain a positive It is often difficult to attain a positive goal without eliminating or reducing one goal without eliminating or reducing one or more types of behaviors, emotions, or or more types of behaviors, emotions, or cognitions, it is appropriate to state cognitions, it is appropriate to state objectives in the negative.objectives in the negative.



► The goals and objectives should be The goals and objectives should be prioritized.prioritized.

► The goals and objectives priority should The goals and objectives priority should mirror the priority assigned to the problems.mirror the priority assigned to the problems.

► The client can work toward achieving one or The client can work toward achieving one or more goals at a time.more goals at a time.

►Objectives tied to two or more goals can Objectives tied to two or more goals can also be address simultaneously and also be address simultaneously and represents the most efficient use of the represents the most efficient use of the client’s and the therapist’s time.client’s and the therapist’s time.



QUESTIONS TO ASKQUESTIONS TO ASK What do you see as your biggest problem?What do you see as your biggest problem? Do you think there is an immediate crisis that needs to Do you think there is an immediate crisis that needs to

be addressed?be addressed? What do you see as your biggest goal in treatment?What do you see as your biggest goal in treatment? How will you know if you have achieved your goal?How will you know if you have achieved your goal? Does the goal involve changing things about yourself?Does the goal involve changing things about yourself? Does the goal involve changing things about other Does the goal involve changing things about other

people?people? What problems do you anticipate in reaching that goal?What problems do you anticipate in reaching that goal? How will you be different after reaching the goal? What How will you be different after reaching the goal? What

positive things will you be doing? What negative things positive things will you be doing? What negative things will no longer be present?will no longer be present?

What skills will help you achieve the goal?What skills will help you achieve the goal?



► The plan for how the therapist will assist the client in The plan for how the therapist will assist the client in resolving their problems and consequently achieving resolving their problems and consequently achieving their goals and objectives.their goals and objectives.

► For clinicians who strictly adhere to a single For clinicians who strictly adhere to a single therapeutic approach (e.g., cognitive-behavioral therapeutic approach (e.g., cognitive-behavioral therapy), the interventions will generally be the same therapy), the interventions will generally be the same for all clients, regardless of what the problems are.for all clients, regardless of what the problems are.

► The selection of the intervention to be used becomes The selection of the intervention to be used becomes more of a challenge for those therapists who are more of a challenge for those therapists who are more eclectic in their treatment orientations.more eclectic in their treatment orientations.

► Interventions are generally direct interaction with the Interventions are generally direct interaction with the clinician or other treatment team member and clinician or other treatment team member and include individual and group interventions.include individual and group interventions.

InterventionsInterventions


► Treatment plans must include the frequency and Treatment plans must include the frequency and duration of the intervention.duration of the intervention.

► In some instances, statements regarding the In some instances, statements regarding the frequency and duration may be nothing more than frequency and duration may be nothing more than guesses based on the therapist’s experience with guesses based on the therapist’s experience with similar clients, problems and treatment goals.similar clients, problems and treatment goals.

► Open ended treatment durations should be avoided Open ended treatment durations should be avoided except in cases for which long-term or continuous except in cases for which long-term or continuous treatment is appropriate (e.g., schizophrenics or the treatment is appropriate (e.g., schizophrenics or the chronically mentally ill).chronically mentally ill).

► The therapist should try to provide a very specific The therapist should try to provide a very specific and accurate determination of frequency and and accurate determination of frequency and duration.duration.



QUESTIONS TO ASKQUESTIONS TO ASK Will the planned intervention enable to client to Will the planned intervention enable to client to

meet all or most of the documented goals and meet all or most of the documented goals and objectives?objectives?

Does the treating therapist have the skills necessary Does the treating therapist have the skills necessary for implementing the planned treatment for implementing the planned treatment intervention?intervention?

Is what the client will be expected to do realistic?Is what the client will be expected to do realistic? Is what the therapist will be expected to do realistic?Is what the therapist will be expected to do realistic? Will the clinician be able to know within a reasonable Will the clinician be able to know within a reasonable

amount of time if the intervention is working?amount of time if the intervention is working? Could a different type of intervention yield the same Could a different type of intervention yield the same

outcome? If so, why was it not selected?outcome? If so, why was it not selected?



► No treatment plan would be complete without an No treatment plan would be complete without an indication of the criteria for successful discharge indication of the criteria for successful discharge from treatment.from treatment.

► Must include the Texas Department of Insurance Must include the Texas Department of Insurance Criteria for discharge from that level of care.Criteria for discharge from that level of care.

► The therapist and client must have an agreed upon The therapist and client must have an agreed upon point at which treatment or a portion of treatment point at which treatment or a portion of treatment is considered complete and the services being is considered complete and the services being offered to the client are terminated or transferred offered to the client are terminated or transferred to a more appropriate LOC.to a more appropriate LOC.

► The criteria should be objective and measurable The criteria should be objective and measurable and should reflect the stated goals and objectives.and should reflect the stated goals and objectives.

Criteria for DischargeCriteria for Discharge


Treatment Plan ReviewTreatment Plan Review► There should always be a time indicated for There should always be a time indicated for

treatment plan review.treatment plan review.► For residential clients, the treatment plan For residential clients, the treatment plan

should be reviewed and updated every 14 should be reviewed and updated every 14 days, sooner if there is a significant change days, sooner if there is a significant change in the client’s condition.in the client’s condition.

► For outpatient clients, the review should For outpatient clients, the review should occur every 30 days or sooner if there is a occur every 30 days or sooner if there is a significant change in the client’s condition.significant change in the client’s condition.


Progress Note Progress Note DocumentationDocumentation


Progress Note Progress Note DocumentationDocumentation

► There should be a progress note documented following:There should be a progress note documented following: each clinical sessioneach clinical session for each day that the client is presentfor each day that the client is present in a residential or detox in a residential or detox

program program at the time of dischargeat the time of discharge

► Progress notes must be signed by the author, and have Progress notes must be signed by the author, and have their credentials clearly documented.their credentials clearly documented.

► Progress notes must contain the date of the session and Progress notes must contain the date of the session and the length of time of the session, with either a beginning the length of time of the session, with either a beginning and ending time or a total time spent with the client.and ending time or a total time spent with the client.

► Progress notes can be written in several different Progress notes can be written in several different formats. The following are recommended:formats. The following are recommended: SOAPSOAP DAP DAP Gillman HIPAA Progress NoteGillman HIPAA Progress Note


S.O.A.P. NotesS.O.A.P. Notes►S = SubjectiveS = Subjective [client’s view of problems or [client’s view of problems or

progress noted, use client’s own words.]progress noted, use client’s own words.]►O = ObjectiveO = Objective [Therapist’s objective [Therapist’s objective

observations of the clients progress.]observations of the clients progress.]►A = AssessmentA = Assessment [Therapist’s assessment [Therapist’s assessment

of the client’s affect, mental status, and of the client’s affect, mental status, and psychosocial functioning.]psychosocial functioning.]

►P = PlanP = Plan [Plan for future treatment as it [Plan for future treatment as it relates to progress noted.]relates to progress noted.]


D.A.P. NotesD.A.P. Notes►D = Data D = Data [Therapist’s observations, [Therapist’s observations,

what the clinician saw and heard, what the clinician saw and heard, quote statements made by the client.]quote statements made by the client.]

►A = Assessment A = Assessment [The therapists [The therapists assessment of the client’s mental assessment of the client’s mental status and psychological functioning.]status and psychological functioning.]

►P = PlanP = Plan [Plan for future treatment [Plan for future treatment as it relates to progress noted and as it relates to progress noted and updating of the treatment plan.]updating of the treatment plan.]


Gillman HIPAA Progress NoteGillman HIPAA Progress Note► This is a new system used to document This is a new system used to document

behavioral therapy notes behavioral therapy notes ► Created by Peter B. Gillman, PhD,Created by Peter B. Gillman, PhD,► Response to the HIPAA regulations around Response to the HIPAA regulations around

psychotherapy notes.psychotherapy notes.


Gillman HIPAA Progress NoteGillman HIPAA Progress Note► The Gillman HIPAA Progress Note contains the The Gillman HIPAA Progress Note contains the

following elements:following elements: Counseling session start and stop timeCounseling session start and stop time Modalities of treatment furnishedModalities of treatment furnished Frequency of modalities furnishedFrequency of modalities furnished Medication prescription and monitoringMedication prescription and monitoring Results of any clinical tests or assessmentsResults of any clinical tests or assessments Summary of SymptomsSummary of Symptoms Summary of Functional StatusSummary of Functional Status Summary of ProgressSummary of Progress Summary of DiagnosisSummary of Diagnosis Summary of Treatment PlanSummary of Treatment Plan Summary of ProgressSummary of Progress


What makes the Gillman HIPAA What makes the Gillman HIPAA Note superior to the SOAP or DAP?Note superior to the SOAP or DAP?

► It requires the clinician to think in more It requires the clinician to think in more behavioral terms.behavioral terms.

► It requires the clinician to focus on presenting It requires the clinician to focus on presenting symptoms.symptoms.

► It requires the clinician to think about It requires the clinician to think about functional environments that the client finds functional environments that the client finds more meaningful to express their more meaningful to express their psychopathology.psychopathology.

► It requires the clinician to think about the It requires the clinician to think about the progress made since the last session.progress made since the last session.


What makes the Gillman HIPAA What makes the Gillman HIPAA Note superior to the SOAP or DAP?, Note superior to the SOAP or DAP?,

Cont.Cont.► It requires the clinician to think about how the It requires the clinician to think about how the

above data might change their diagnostic above data might change their diagnostic thinking.thinking.

► It requires the clinician to think about changes It requires the clinician to think about changes to their treatment plan and recommendations.to their treatment plan and recommendations.

► It requires the clinician to think about the It requires the clinician to think about the prognosis until the next treatment sessionprognosis until the next treatment session..


General ConsiderationsGeneral Considerations

►Think about what you will write before Think about what you will write before you write it. you write it.

►Sign and Date every note. Sign and Date every note. ►Check your notes for grammatical and Check your notes for grammatical and

spelling errors. spelling errors. ►Limit the use of abbreviations - check Limit the use of abbreviations - check

with site as to which abbreviations are with site as to which abbreviations are acceptable. acceptable.


General ConsiderationsGeneral Considerations►Errors on hand written notes should Errors on hand written notes should

have a single line through them, write have a single line through them, write 'error', initial, and date. 'error', initial, and date.

►Write legibly. Write legibly. ►Avoid blank spaces between entries. Avoid blank spaces between entries. ► Include client name and case number Include client name and case number

on each page. on each page. ►Use direct quotations when reporting Use direct quotations when reporting

clinically relevant client quotations. clinically relevant client quotations.


General ConsiderationsGeneral Considerations►Describe what was observed not just Describe what was observed not just

your opinion about what was observed. your opinion about what was observed. ►Tie notes into your treatment plan Tie notes into your treatment plan

goals and objectives. goals and objectives. ►Be as brief as is necessary - that is put Be as brief as is necessary - that is put

enough information down to complete enough information down to complete a note well, but don't put more a note well, but don't put more information than is necessary. information than is necessary.

►Clearly note any risk assessment data Clearly note any risk assessment data and contracting. and contracting.


General ConsiderationsGeneral Considerations►Remember the chart is a legal document. Remember the chart is a legal document. ►Because it is a legal document, you should Because it is a legal document, you should

start your note right after the last note in start your note right after the last note in the chart so it will be chronological. the chart so it will be chronological.

►For neatness sake you may want to start at For neatness sake you may want to start at the top of a page, so strike out any blank the top of a page, so strike out any blank space above your note. space above your note.

►You should also provide room for your You should also provide room for your supervisor to amend your note at the end.supervisor to amend your note at the end.


General ConsiderationsGeneral Considerations

►Do not leave blank lines in between Do not leave blank lines in between text. text.

► If you make a mistake, simply cross If you make a mistake, simply cross out the word with a single horizontal out the word with a single horizontal line, write “error”, and initial it. line, write “error”, and initial it.

►Do not scribble/white out a mistake. Do not scribble/white out a mistake.

clinical documentation

Documents

educationaleducational

employmentemployment

treatment recommendationspress

drug use history usefamily

assessmentthe assessment

directionshow clients

clients needspress

clients life