7. Documentation

Documentation involves the recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client-related data.

The competencies in this area, are:

1. Demonstrate knowledge of accepted principles of client record management. 

  • Regulations pertaining to client records.
  • The essential components of client records, including release forms, assessments, treatment plans, progress notes, and discharge summaries and plans.
  •  Composing timely, clear, complete, and concise records that comply with regulations.
  • Documenting information in an objective manner.
  • Writing legibly.
  • Using new technologies in the production of client records.

2. Protect client rights to privacy and confidentiality in the preparation and handling of records, especially in relation to the communication of client information with third parties. Our knowledge and skills in this area, are:

  • Federal, State, and program confidentiality rules and regulations.
  • The application of confidentiality rules and regulations.
  • Confidentiality rules and regulations regarding infectious diseases.
  • Apply infectious disease regulations as they relate to addictions treatment.
  • The legal nature of records.
  • Request, prepare, and complete release of information when appropriate.
  • Protect and communicate clients’ rights.
  • Explain regulations to clients and third parties.
  • Provide security for clinical records.
  • Willingness to seek and accept supervision regarding confidentiality rules and regulations.
  • Respect for clients’ rights to privacy and confidentiality.
  • Commitment to professionalism.
  • Recognition of the absolute necessity of safeguarding records.

3. Prepare accurate and concise screening, intake, and assessment reports. Essential elements of screening, intake, and assessment reports, include:

  • psychoactive substance use and abuse history
  • physical health
  • psychological information
  • social information
  • history of criminality
  • spiritual information
  • recreational information
  • nutritional information
  • educational or vocational information
  • sexual information
  • legal information

4. Record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.

  • Current Federal, State, local, and program regulations.
  • Regulations regarding informed consent.

5. Record progress of client in relation to treatment goals and objectives.

  • Appropriate clinical terminology used to describe client’s response to intervention and progress made toward completing treatment goals and objectives.
  • How to review and update records:
  1. Prepare clear and legible documents.
  2. Document changes in the treatment plan, client status, client response to and outcome of interventions, level of care provided, and discharge status.
  3. Use appropriate clinical terminology and standardized abbreviations.
  4. Note client’s strengths and limitations in achieving treatment goals.
  5. Record client’s response to and outcome of interventions.
  6. Record changes in client’s status, behavior, and level of functioning.
  1. Note limitations of treatment provided to client.

6. Prepare accurate and concise discharge summaries.  The components of a discharge summary, include:

  • client profile and demographics
  • presenting symptoms
  • diagnoses
  • selected interventions
  • critical incidents
  • progress toward treatment goals
  • outcome
  • continuing care plan
  • prognosis
  • recommendations

TAP 21

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