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18 Cards in this Set
- Front
- Back
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Charting the results of the assessment and treatment plan; writing reports, progress notes, discharge summaries and other client related data |
IC & RC REPORTS and RECORD KEEPING |
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The recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client related data.
______________________ are product oriented administrative functions. Reports include such formal items as the written assessment, treatment plan and discharge report. Everything a counselor does for and with a client should be DOCUMENTED. The start of documentation is with the initial screening process. It continues with the administrative paperwork of intake and orientation. Preparing reports and record keeping is a frequent function of a substance abuse counselor. Although the majority of a counselors time may be in the direct counseling function, all aspects of client treatment requires some form of a report or record to be kept. |
Definition of reports and record keeping |
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(S) Subjective: the counselor records what the client said during the counseling session and what points are made. Also, naming the specific objective that was a focus of the session is an appropriate comment to note in the "Subjective" section. The specific activities conducted during the session in support of the treatment plan should be included in this section. Do not interpret what the client said or evaluate the results of the activity in this section.
(O) Objective: the counselor should record an objective impression of the client for example physical appearance, demeanor, and observed behavior displayed during the counseling session.
(A) Assessment: the counselor should record in behavioral terms his or her clinical impressions of the client. For example, interpretation of the clients behavior, progress towards completion of objectives, and prognosis.
(P) Plan: the counselor should record the plan for the next session or client needs that should be pursued through case management activities. This allows the counselor to be Forward thinking in order to advance the client's progress. Also, it will help other members of the treatment team and future counselors to quickly see where a client is at a specific point in the treatment plan. This is especially important should the primary counselor be unavailable and another counselor needs a counsel the client.
It is generally accepted that reports and record keeping are necessary function of being an alcohol and drug abuse counselor. Keeping records facilitates communication among the treatment team and is invaluable to other counselors who may see the client when the primary counselor is not available, or when the client is referred to another treatment service. Adequate reporting and record keeping also helps a counselor's supervisor provides skillful supervision of the counselors work with the client. Without reports and records, and agencies license or funding would be in jeopardy. Documents that reveal the identity, diagnosis, prognosis, or treatment of a client must be marked to indicate their protected and unauthorized disclosure is prohibited. |
One common method of documentation is the Subjective, Objective, Assessment, and Plan (SOAP) cased note format. |
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The client should see the process of client record-keeping with each client-counselor interaction. Few clients question the need for a counselor to keep a record of what is happening and treatment and most expected and evaluation will be done on them. Usually, a short comment during the initial assessment and again in the first counseling session about the counselors need to make some notes in order to keep things straight is all that is needed to alleviate a client's concerns. If a client were concerned about the counselor keeping a record, this would both be diagnostic and perhaps an issue to pursue in treatment. If a client's concerned about record-keeping exceeds a passing comment, the counselor may want to consider a consultation for the possibility that the client has a dual diagnosis and may display the characteristics of paranoia. |
From the Clients point of view |
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If there is one function of an alcohol and drug abuse counselor's job that is spoken about with disdain, it's doing reports and keeping records- the paperwork. Once a counselor understands the importance of reports and record keeping there is often acceptance of doing a good job of documentation. |
From the counselor's point of view |
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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. The intake, assessment and treatment planning task all require thorough and thoughtful documentation in order to adequately form the basis of the client's treatment experience. Once these are in place, the progress notes should objectively summarize a client's activities and progress towards identified goals. Progress notes are also written following individual sessions, group therapy, family sessions and other activities which have clinical significance. Any other critical incidents or crisis should also be noted. Progress notes must always be dated and signed.
The discharge plan is created just prior to our client's discontinuation of treatment and generally specifies post treatment recommendations. The discharge summary presents an overview of the client's treatment experience with a statement of prognosis for the future. 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 good standing of the treatment program rely on responsible documentation. |
Record keeping |
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A. Documentation of client goals and progress made toward achieving those goals is important for both the client and the counselor. B. Documentation is critical for maintaining clear communication with other treatment team members regarding client progress. C. Reports can be very useful for others working with a 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. D. Funding and licensing agencies pay close attention to record keeping and often have particular recordkeeping requirements E. The clinical supervisor should regularly review all client records and provide feedback to the counselor regarding content, format, etc. |
TASKS |
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A. Intake B. Assessment C. Treatment Plan D. Treatment Plan Reviews E. Progress Notes-:JCAHO requires that progress notes: 1. Be part of a client's record 2. Document the implementation of the treatment plan 3. Serve as the basis for plan review. 4. Document all treatment delivered to the client 5. Describe the client's response to treatment, change in conditions, outcome of treatment, and achievement of goals. 6. Include written reports from outside service providers |
Typical Forms |
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1. Developed by client and counselor 2. Becomes permanent part of client's record, and may be shared with future service providers after discharge 3. Specifics might include: A. Where client will live after discharge B. Whether or not client will receive outpatient counseling C. Whether or not client should attend self-help groups D. How client will obtain work or return to school E. Financial plan for self-support, if necessary F. Recommendation for continuation of prescribed medication, if appropriate |
Discharge Plan |
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JCAHO requires: 1. Discharge of summary entered into clients record within 15 days after discharge. 2. Inclusion of the results of the intake assessment and diagnosis 3. Inclusion of summaries of: A. Significant findings B. Achievement of goals C. Course of treatment D. Final assessment E. Recommendations for further treatment F. Written after care plan based on clients needs as reassessed, to be developed by counselor with input from client and family. |
Discharge Summary |
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A counselor knows the kinds of reports prepared during the various stages of treatment and know how the reports and other available information are integrated into the treatment plan in order to facilitate the client's care. |
Prepare reports and relevant records integrating available information to facilitate the Continuum of Care. |
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A counselor knows how to chart ongoing information for a client and knows what information is important to document. It is the counselor's responsibility to personally understand not only how and what is necessary to chart, but also to have an understanding of why charting is important to the client and the treatment plan. |
Chart pertinent ongoing information pertaining to the client. |
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A counselor understands how information from written documents are used to benefit the client. A counselor understands how a report from another professional is used to identify a client's problem or need. For example a psychologist evaluation might identify a number of clients strengths and weaknesses that could then be incorporated into the treatment plan. A consultation with a psychiatrist or a nutritionist might be helpful and directly improving the client's mental or physical health. For a professional officer's reporter other legal documents may be important when addressing aspect of the clients aftercare program. |
Utilize relevant information from Writtenn documents for client care |
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1. Protect clients right to privacy and confidentiality according to best practices in preparation and handling of records, especially regarding the communication of client information with third parties. 2. Obtain written consent to release information from the client and/or legal guardian, according to best practices and administrative rules, to exchange relevant client information with other service providers. 3. Document treatment and continuing care plans that are consistent with best practices and applicable administrative rules. 4. Document clients progress in relation to treatment goals and objectives. 5. Prepare accurate and concise reports and records including recommendations, referrals, case consultations, legal reports, family sessions, and discharge summaries. 6. Document all relevant aspects of case management activities to assure continuity of care. 7. Document process, progress, and outcome measurements |
Documentation |
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In clients words: "I want to stop fighting with my wife and get my job back so I have to stop using". Mr. Smith states that his cravings for heroin are still strong and "about 6 times a day" he still thinks about leaving residential SUD treatment and going to his old neighborhood to score drugs. Mr. Smith states that after 5 weeks, he's finally comfortable speaking in group and believes that treatment is helping. He wants to stay clean from heroin, and believe he's "better" but still says "I'm not strong enough: but I still can't stop thinking about the feeling of using and still have trouble getting it out of my head." But overall, he states that he's "getting better" because during the last visit with his wife, he said that for the first time he apologized for "giving her grief" and they had a good visit. |
Example of Subjective |
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Mr. Smith appears calm and engaged in session. There are no visible signs of withdrawal, sweating, tremors, or agitation, and clients drug tests during residential SUD treatment have all been negative. He is still easily distracted and reports occasional anxiety, but his attention and concentration is improved, as evidenced by talking for 5 minutes about wife and being able to reflect on his past treatment without issue. His mood remains mostly flats but he laughed when talking about his children and a humorous incident during a group counseling session |
Example of OBJECTIVE |
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Overall Mr Smith is slowly and improving. His cravings have reduced from "all the time" to about 6x a day. He is more engaged in treatment and during both individual and group sessions, and has identified high-risk triggers for use (anger fights with his wife, and boss, and being around the old neighborhood). He is learning to use his coping skills (relaxation,practicing delay and examining the evidence when he's angry) and reports he likes going to men's NA meetings because he feels like the men "get it" and "understand me" However, given his 30 year history of heroin use and strong cravings, he needs more time solidifying the use of his coping skills, along with learning new skills to manage cravings and his intense emotions which have previously been triggers to use. Given his ongoing challenges and the severity/frequency/duration of his heroin use, he may be appropriate candidate for medication assisted treatment (MAT. Although he initially said that he wasn't interested in considering the use of medications to help with his treatment and now says he's like to know more after using motivational interviewing techniques to engage the client and speaking with him about the pros and cons of MAT and how it may help them achieve his recovery goals |
Example of ASSESSMENT |
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1. Provided additional literature and information regarding MAT for discussion during next session 2. Will continue motivational interviewing techniques with regard to MAT by discussing how MAT might assist client with his goals (stop fighting with his wife, get job back, etc). 3. Will request additional 30-day extension of residential treatment to address ongoing cravings, and the fact that positive progress is being made with current interventions. 4. Plan to continue family sessions with wife, who is strongly supportive of recovery 5. Will continue to monitor client and relapse potential closely |
Example of PLAN |
