Ch 6: Documentation and record keeping in clinical settings Flashcards
Two purposes of maintaining clinical documentation
- facilitates the provision of the best possible services for clients
- documents that the level of care provided to a client meets the standards of care found in the counseling profession
written records have the potential to
enhance the counseling experience
accelerate client progress
increase access to various services
protect both counselors and clients
**no universal standard exists for the style and format
clinical documentation
involves any written and/or electronic record pertaining to contact between the client and counselors and work that has occurred within the counseling relationship
EX: case notes, assessment, treatment plans, confidentiality agreements, consent for services, billing notices etc.
purpose and role of clinical documentation
track service delivery and progress
serve as memory aid
case notes
facilitate communication among treatment professionals and promote continuity of care
types of documentation found in clinical records
client ID info
informed consent docs
financial arrangements
psychosocial assessment
mental status examination results
release of info
ancillary info (test results, medical records, communication with third parties)
treatment plans
case notes
informed consent documents
include a variety of information describing what the counseling process will look like, what the client can expect from the counselor, what the client will be expected to do, how services will be arranged and how they will be paid for, and what resources the client has should the serves provided be deemed inappropriate or ineffective
consent
sought from individuals who are legally able to provide it
assent
refers to the personal agreement to engage in therapeutic activities with the counselor
with children and minors specifically
psychosocial assessment
comprehensive evaluation of a clients mental health, well being, and social functioning
common sections of a psychosocial assessment
- addresses the clients presenting problem/document the reason for seeking counseling
- looks at the clients history with the presenting concern
- family history
- history of mental health
mental status examination (MSE)
structured assessment of a client’s behavioral and cognitive functioning
used to develop baseline understanding of a clients presentation and aid in conceptualizing a potential diagnosis
subjective tool
usually done by psychiatrists/psychologists (counselor may participate)
components of MSE
appearance
level of alertness
speech
behavior
awareness of surroundings
mood
affect
thought process
thought content
memory
ability to perform calculations
judgement
higher functioning and reasoning
release of information
clients maintain legal ownership of their case files; client must consent/authorize to any release of info
treatment plans
a synopsis of a counselors work with a client
include description of clients presenting problem, potential diagnosis that may apply, goals established, and strategies/interventions planned to reach goals
three primary features of treatment plans
an overview: brief recap of why client is in services, symptoms experienced, how problem addressed/etc.
listing of long-term goals
listing of short-term goals
case notes
the session-to-session archives counselors keep about their work with clients
document what was discussed in session , the outcome of discussions, and any plans for future sessions originating from these discussions
clear, concise, and accurate
SOAP note
Subjective-objective assessment plan
STIPS note
signs and symptoms
topics of discussion
interventions
progress and plan
special issue
seven cognitive goals of STIPS
- to acquire relevant facts about the client and case
- to form diagnoses or a clinical understanding of the clients presenting problems
- to form meaningful and effective treatment plans and goals that directly relate to a clients presenting problems
- to understand within session process when working with clients and the relevant domains to track regarding a clients problems and within session goals
- to understand the counseling process across sessions with clients and how to longitudinally track a clients problems and overall progress in treatment
- to evaluate and adjust, their treatment interventions to best serve clients needs
- to use relevant criteria to evaluate the usefulness of counseling for clients at the end of treatment and to understand how their counseling interventions have led to a particular outcome in treatment for this specific client
DAP case notes
describe, assess and plan
elements of good clinical documentation
purposeful
ethical
comprehensible
must be done in timely manner/up to date
time-sensitive client info
CPS or APS reporting
case notes
conditions for releasing notes
subpoenaed by a judge (legally required to break confidentiality)(only essential information though, not everything)
