Conducting an Interview and

Creating a Plan of Care

Chapter 8

Intentional Interviewing and Counseling

The Counseling Process

Interview

Assessment

Plan of Care/Treatment Plan/Action

Plan

Interview

The interview: probably the most important area of assessment is the

formal information gathering conducted during the interview. From the

intake interview to the formal psychosocial assessment interview; the

helper plays a pivotal role in gather the information that will be used to

direct treatment efforts. It is essential that the help develop the skills of

active listening, questioning, and interpreting client messages. The

qualities of genuineness, empathy, and unconditional positive regard can

assist in making this a collaborative effort between the helper and the

client.

Screening and Assessment

The use of formal screening and assessment tools can assist in

information gathering by providing standardized instruments which have

been proven reliable and valid through research.

These instruments in and of themselves are not purely diagnostic, but

rather provide a helpful guiding framework to evaluate the likelihood

of a clinical problem.

Screening, assessment, and especially standardized testing require

specialized training to administer and interpret. It is critical that the

client be informed of the nature and purpose of the evaluation

instruments being used and that the results be shared with them in

and developmentally appropriate manner.

Observations

Observations can take many forms, from noting interactions during group

counseling and individual sessions, to observing the client’s interaction

outside of group during common time in a residential treatment setting, to

observing the client at work or school. The information gathered through

observation can be helpful in understanding the client, especially when the

observation is made in the client’s natural environment.

Self assessment

Often the best person to assess the client is the client themselves. The

use of client self-assessment tools can be valuable in helping the client to

identify issues, trends in thinking, and problems which should be

addressed during treatment. There are a number of structured ways to help

the client to become more self-aware, they can include: keeping a journal of

feelings, triggers, etc.; maintaining a list of strengths and weaknesses; completing

a lifeline. The important thing is to get the client involved in taking a critical look

at themselves.

Other Information

Collateral information is obtained with the client’s written permission and

can include information from: significant others, parents, siblings,

employers, teachers, probation or parole officials, etc. In some cases it is

helpful for the counselor to form their own evaluation of the client before

reviewing collateral information then using it as a method to validate their

judgments.

Previous History of Treatment

While other record, such as school and court records may be available,

the most commonly sought record by helping professionals is previous

treatment records. Reviewing previous treatment records can be a

valuable asset in developing a comprehensive treatment plan. The

success and failure of previous treatment efforts can provide insight into

what has worked in the past and give the helper a jumping off point.

Psychosocial History

The psychosocial history is a formal, comprehensive evaluation of the

information gathered. Often a formal clinical interview is held for the sole

purpose of gathering this information; other relevant information is then

considered and a formal document is produced which may include

diagnostic impressions of the client. In the chemical dependency

counseling field this can be done by a Counselor Intern under the

supervision of a QCC (Qualified Credentialed Counselor including an

LCDC. In other psychiatric settings a credentialed counselor could include

an: LPC; LMSW; Psychologist, or Psych Associate; all of which have a

masters degree or higher.

Record Keeping/Documentation

•

• Report and Record Keeping includes documenting or charting the results

of the assessment and treatment plan, writing reports, progress notes or

clinical notes, discharge summaries and other client related data.

• Record keeping is one of the most critical tasks of any counselor, in terms

of quality and continuity of care.

• Record keeping begins with the first contact that is made by the client with

a treatment program (typically called a screening) and continues through

the evaluation and treatment process.

• Notes in the clinical record are typically called Progress or Clinical Notes.

Progress or Clinical Notes should objectively summarize the client's

activities and progress toward resolution of problems and meeting the

identified goals. Progress notes are written following individual, group or

family sessions and other activities which have clinical significance. The

Treatment Plan is a part of the clinical record, and is a legal document.

Records

It is critical that all reports and record inclusions be written legibly and with

correct spelling and proper usage of grammar and punctuation. Records

are often reviewed by supervisors and other staff members and must be

readable to be useful. The agencies ability to successfully bill for client

services may depended on whether your record entries can be read and

reflect appropriate services. It is imperative that the client's progress and

significant activities be accurately documented. Records must also

include appropriate Releases of Information forms for information that is

requested from or revealed to others.

• Finally, accurate Record keeping is necessary from the legal, funding and

ethical perspectives. The client's treatment and recovery, as well as the

reputation of the treatment program rely on documentation.

Documentation Tasks

• Documentation of client goals and progress made toward achieving those

goals is important for both the client and the counselor.

• Documentation is critical for maintaining clear communication with other

treatment team members regarding client progress.

• Reports can be very useful for others working with the client, i.e.

physician, parole or probation officer, future treatment provider. A

signed Release of Information form is required for sending client

information to them.

• Funding and licensing agencies pay close attention to Record keeping

and often have particular Record keeping requirements.

• The clinical supervisor should regularly review all client records and

provide feedback to the counselor regarding content, format, etc.

• Legal Documentation-the client's record is a legal document and is

admissible in court as evidence.

Types of Clinical Notes/Progress

Notes/Documentation / Charting:

Narrative Charting - a description (narration) of information, and chronological

charting records data in sequence as time moves forward; commonly used

with the source oriented record. Disadvantages of Narrative

Documentation: it is difficult for a reader to find all the data about a specific

problem without reading all of the recorded information; the record is very long

and tedious to read.

SOAP Format

SOAP Format - an acronym for:

• S subjective data about a specific problem

• O objective data about a specific problem

• A assessment/conclusions the counselor draws

• P plan of action or action taken to address the problem

• S stands for Subjective data report what the client perceives and the way the client expresses

it. This section usually consists of client quotes, recorded verbatim.

• O stands for Objective data include measurable findings and observations made by the counselor

using their senses, client responses and other "concrete" facts. This includes the clinician’s

observations of the client’s behavior, the reported observations of other professionals,

psychological test data, and functionally significant occurrences (e.g., suspension from school).

• A stands for Assessment is the recording of counselor interpretations and conclusions from the

subjective and objective data.

• P is for Plan, that is what the counselor intends to do in response to the assessment. This heading

can include both immediate and long-term plans for treatment techniques, testing, referral and

follow-up.

SOAP-IER

Recently the additions of IER to make for SOAPIER includes the following:

• I stands for intervention or plan implementation. This section gives a more

short-term and detailed description of the counselor’s interventions than

what is recorded under the plan heading.

• E is for the counselor’s evaluation of the effectiveness of the

intervention. In the plain SOAP format, intervention outcomes are

described under S or O; here, they have their own heading.

• R is for revisions of the plan. In the SOAP format, this would be described

under P. In the SOAPIER format, the P section describes the

implementation of the original plan, and the R section records mid-course

changes in the plan. In some facilities R is used for the client’s response

to both the plan and evaluation.

Guidelines for Recording in the Clinical Record

• The client's record is a legal document. Use correct grammar, spelling, punctuation.

• Time and date each entry to include duration and nature of contact, i.e. individual, group, collateral.

• Complete ALL of the information requested on a particular form-date, time, clients identifying

information, target dates, initials - do not leave blanks on forms.

• Do NOT record information about something before it is actually done. Record as soon as possible

after contact.

• Do not leave blank lines between the last entry and your entry.

• Do not document for someone else; do not allow someone else to document for you.

• All information you record on a clients record must be about that client - do not refer to other clients by

name etc.

• No retaliatory or critical comments about the client, or care by other health care professionals are

allowed.

• Access to records is restricted - DO NOT give it to someone to read unless you follow agency policy

regarding the request.·

• Always write legibly. Use a black or blue-black pen only. Never document in pencil.

Dark ink is reproducible on microfilm and when duplication is allowed (court cases

etc.). No erasures or obliterations are allowed.

• Entries MUST be legible.

• Use abbreviations that are standard and acceptable in THAT AGENCY. If in doubt,

do not use abbreviations.

• You must place your signature after each entry.

• You must use your legal signature and your title.

• Example: Jane Doe, CI, or Joe Dole, Central Texas College (CTC) Mental

Health Services Practicum Student.

• Document with accuracy, do not draw "general" conclusions. Instead of

writing: "The client had a bad attitude in group", write this: The client sat silently in

group with his hands folded across his chest and did not verbally participate".

• Document sequentially; time the events as they occur.

• Be appropriate, complete, but brief. Only information that pertains to the client's

current problem is recorded. A client's disclosure that she was addicted to heroin 20

years ago, and she is currently admitted for something totally unrelated, WOULD

NOT be recorded unless it had a direct bearing on the client's current problem. If

a client wants to leave against medical authority (AMA), follow all agency guidelines.

Guidelines for Recording in the Clinical Record

(cont…)

To Correct Errors

• No white out

• No erasures

• Draw one line through the incorrect information, so that it can still be read. Initial and

follow agency policies. Usually, the word "Error" is written, or "Error in Entry" or "Mistaken

Entry" is written. Do NOT destroy any part of the record.

• If you are charting out of sequence, chart "Late Entry".

• Do NOT defame clients, call them names, or make derogatory statements about

them. Example of a totally unacceptable entry:

• "Client is an unlikable person who is demanding unnecessary attention".

• If you question what you should do about following an order by a

physician/psychiatrist etc., document that clarification was sought and from whom.

The Mental Status Exam

The Mental Status Exam: The mental status

exam is often completed by the helper and is a

statement of (1) how the client presents himself

or herself (general description), (2) the client’s

feeling state (emotions), (3) the client’s memory

state and orientation to the world (cognition), (4)

the client’s ability to think clearly (thought

disturbances).

General Description

General Description: under the general description of the

client would be the following information:

• Appearance: to include dress and grooming; physical

characteristics; posture and gait.

• Attitude and interpersonal style.

• Behavior and psychomotor activity.

• Speech and language including: rate, clarity, pitch, volume,

tone, quality, and resonance and any abnormalities.

Emotions

Emotions: this is the area where the clients feeling stage is

evaluated and would include:

• mood (euthymic, expansive, euphoric)

• affect (broad, appropriate, constricted, blunted, flat, labile,

anhedonic)

• neuro-vegetative signs of depression.

Cognitive Functioning

Cognitive Functioning: this section of the mental status exam

looks at a number of cognitive functions including:

• orientation and level of consciousness

• attention and concentration

• memory: immediate (a minute or less); recent (a minute to days

or weeks); remote (weeks to years)

• ability to abstract and generalize

• information and intelligence: fund of knowledge; estimate of

intelligence.

Thoughts and Perceptions

Thoughts and Perceptions: is used to evaluate thought

disturbances and includes:

• disordered perceptions: illusions; hallucinations;

depersonalization and de-realizations.

• thought content: distortions; delusions; ideas of reference;

magical thinking.

• thought content: flow of ideas; quality of associations; pre-

occupations: somatic; obsessions and compulsions; phobias.

• suicidal; homicidal and impulse control.

• insight and judgment.

• reliability.

Security of Records

Security of records: clinical records must be treated as official

documents and maintained in an appropriate manner. Access

to records should be closely monitored and limited to

appropriate personnel. Each agency will have a policy and

procedure for maintenance of clinical records which will often

be driven by the licensing body who they are responsible to. It

is generally understood that clients have a right to see their

records. Your agency should have a policy and procedure for

clients to review or obtain a copy of their records.