CLINICAL DOCUMENTATIONSUSAN KILMAN LCSW, AADC

WHAT IS IT

• CD is a clinical tool that provides clients with the opportunity to provide their input and perspective on services and progress, and allows clients and providers the opportunity to clarify their understanding of important issues and focus on outcomes.

• Includes paper records including files, case notes, letters, reports, continuation sheets, diaries, post-it notes, computer print outs, electromagnetic records including discs, servers and databases audio-visual records including films, tapes, videos and CDs, photographs, and lab results.

• Good records ensure both good and ongoing patient care and good medico-legal and risk management practice.

WHAT WE BELIEVE

• Documentation has become “The ENEMY”

• Clinicians count on “no-shows” and “cancellations” to complete paperwork and catch up

• Clinicians report that documentation competes with time spent with clients and is divorced from the clinical work

• There is always too much to be done in too little time

• “No one really looks at it any way.”

THE TRUTH

• CD validates our existence

• CD can be an exceptional clinical tool when utilized in a collaborative way with clients/patients

• CD can provide clarity of goals and illustrate clinical progress

• CD can tell the story of a changed life with us as its narrator

• CD provides accountability

• Be prepared to say more with fewer words

• Be prepared to be more transparent as a provider

IS THIS REALLY NECESSARY

• Medical Necessity implies focus on functioning in three key documents:

A) Diagnostic Assessment: Signs and symptoms are not enough; must include specific functional impairments related to diagnosis

B)Treatment Plan: Symptom-based goals are not enough; must include functional goals as well.

C)Progress Notes: Not purely subjective must have specific objective/measurable improvements in functioning to indicate treatment is working

SHOULD BE A COLLABORATIVE EXPERIENCE WITH THE CLIENT/PATIENT

FACT, ASSUMPTIONS, AND OPINIONS

• Fact: A fact is information seen or heard. It is objective in nature.

• An assumption/inference: A statement about the unknown based on the known.

• Opinion: A subjective view that should be based on facts

“It is my opinion that _________because _______________(fact)”

Example : “Mr. B. has poor prognosis for recovery due to a extensive history of not appearing for appointments and failure of multiple drug tests.

THE STORY

The 12 core functions:

• http://dhhs.ne.gov/publichealth/Documents/12_Core_Functions.pdf

INTAKE/ASSESSMENT

• Diagnoses Talk with client about what diagnoses really are and then share your current conclusions and document with client. Use the symptoms they describe and how they are impacting functioning.

• Interpretative/Clinical Summary Say, “OK, let sum up what we’ve discussed today.” Document with the client. Identified Needs/ Problems. Develop clearly identified and prioritized Behavioral Health Needs (Problem Areas) that can be used to establish goals.

• Utilize the current symptoms and functional needs to identify the clients assessed need. This will be the link from the assessment to the goal.

• Say, “So the areas that we’ve identified that we should work on together are 1: … , 2:…, etc.” If the client doesn’t want to work on one or more of these, record that with the client.

https://www.integration.samhsa.gov/mai-coc-grantees-online-community/Breakout4_Collaborative_Documentation.pdf

TREATMENT GOALS

• Definition:

• A goal is a general statement of outcome related to an identified need in the clinical assessment.

• A goal statement takes a particular identified need and answers the question, “What do we want the outcome of our work together to be, as we address this identified need?”

• Discuss and enter a collaborative statement that makes sense to the client.

OBJECTIVES

• Objectives: Attempt to develop a measurable and observable outcome that: Will be apparent to the client; Meaningful to the client; Achievable in a reasonable amount of time ; Can be assessed in an objective way

• Remember: Objectives are important to allow you and the client to tell if the work you are doing together is working.

INTERVENTIONS

• Interventions: Discuss the Intervention(s)/Strategy(s) that will be used to help achieve the objective. Document with the client. Help them understand that this is what you will do to help them achieve their objectives.

• Services: Discuss the modality/service for the intervention(s) and the frequency and duration. Review recommended frequency and confirm the commitment

PROCESS OF SESSION

• The plan was a much more powerful section when completed with the client. Tasks or skills that the client had a agreed to try were noted and reviewed at the beginning of the next session. (What is the client going to do)

• Tasks that I agreed to complete were noted and reviewed at next session as well. (What is the staff going to do)

• Topics that we did not have time to address. (What are we going to do together at the beginning of the next session)

WHAT DO I INCLUDE IN A PROGRESS NOTE

1. New, salient information provided by client

2. Changes in mental status

3. Goal(s) and objective(s) that were focused on

4. Interventions provided

5. Client’s response to intervention (today) “What did we do today that was helpful?”

6. Client’s progress re: the goal/objective being addressed

7. Plan for continuing work

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PROGRESS NOTE EXAMPLES

• See handout “Writing Clinical Case Notes”

• See handout “Counseling Session Soap Note”

https://www.basic-counseling-skills.com/c-sample-sessions.html

OTHER METHODS

• P-I-R: Problem(s)-Intervention(s)-Response(s)

• G-I-O: Goal(s), Intervention(s), Objective(s) –

• G-I-R-P: Goal(s), Intervention(s), Response(s), Plan

• D-A-P: Data, Assessment, Plan

See the handout on possible words to use in clinical documentation.

THINGS TO AVOID

• Never use casual abbreviations (use medical abbreviations)

• Do not take shortcuts at the cost of clarity (re-read out loud)

• Do not use generalizations or over-interpretations

• Grammatical errors…Spell check before finishing case note

• Avoid negative, biased, and prejudicial language. Write in a style that is factual, objective/unbiased, specific, and to the point without jargon.

• Omit details of the client’s intimate life unless it’s relevant to care plan.

• Avoid using medical diagnoses that have not been verified by a medical provider. – client is depressed, rather say client states that he is having feelings of sadness or depressed mood). OR describe symptoms (client describes seeing hallucinations or is feeling sad on a daily basis)

CLINICAL CHART AUDITS

• See example of clinical audit form from Beacon

ETHICAL GUIDELINES

• Review handout, “Documentation in Social Work”.

ADDITIONAL SOURCES OF INFORMATION

• Baird, Brian N. (2014). The internship, practicum, and field placement handbook. 7th Ed. New York: Routledge.

• Cameron, Susan & turtle-song, imani. (2002). Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80, 286-292.

• Heifferon, Barbara A. (2005). Writing in the health professions. New York: Pearson/Longman.

• Kettenbach, Ginge. (2009). Writing patient and client reports: Ensuring accuracy in documentation. 4thEd. F.A. Davic Co.

• Moline, Mary E., & Borcherding, Sherry. (2013). The OTA’s guide to documentation: Writing SOAP notes. 3rd Ed. Thornfield, NJ: Slack Inc.

• Moline, Mary E., Williams, George T., & Austin, Kenneth M. (1998). Documenting psychotherapy: Essentials for mental health practitioners. Thousand Oaks, CA: Sage.

• Sullivan, Debra D. (2011). Guide to clinical documentation. 2nd Ed. F.A. Davis Company.

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