DOCUMENTATION:

ASSESSMENT,
TREATMENT PLANS &
PROGRESS NOTES
Presented by
Jill S. Perry, MS, NCC, LPC, CAADC, SAP

August 23, 2017

What does COD Look Like?

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Healing for Adults, Youth and Families
JP Counseling
Healing for Adults, Youth and Families
Actual Medical Quotes

■ The patient had waffles for breakfast and anorexia for lunch.

■ The baby was delivered, the cord clamped and cut and handed to the pediatrician,
who breathed and cried immediately.

■ The patient was in his usual state of good health until his airplane ran out of gas
and crashed.

■ I saw your patient today, who is still under our car for physical therapy.
Actual Medical Quotes

■ The patient lives at home with his mother, father, and pet turtle who is enrolled in
day care three times a week.

■ Examination of the genitalia was completely negative except for the right foot.

■ While in the emergency room, she was examined, X-rated and sent home.

■ The skin was moist and day.

Actual Medical Quotes

■ The lab test indicated abnormal lover function.

■ Coming from Detroit, this man has no children.

■ Patient was alert and unresponsive.

■ When she fainted, her eyes rolled around the room.

■ Rectal exam revealed a normal size thyroid.

Keep Taking the Medicine

■ Patient: It's been one month since my last visit and I still feel
miserable.

■ Doctor: Did you follow the instructions on the medicine I gave you?

■ Patient: I sure did - the bottle said 'keep tightly closed.'

SAMHSA Addiction Counseling
Competencies
■ The recording of the screening and intake process, assessment, treatment plan, clinical
reports, clinical progress notes, discharge summaries, and other client-related data.
■ 1. Demonstrate knowledge of accepted principles of client record management.
■ 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.
■ 3. Prepare accurate and concise screening, intake, and assessment reports.
■ 4. Record treatment and continuing care plans that are consistent with agency
standards and comply with applicable administrative rules.
■ 5. Record progress of client in relation to treatment goals and objectives.
■ 6. Prepare accurate and concise discharge summaries.
■ 7. Document treatment outcome, using accepted methods and instruments.
Purposes of Clinical Documentation

■ To document professional work:

– To record what was done, by whom, with, to, for, and/or on behalf of whom,
when, where, why, and with what results

– To document assessment and differential diagnosis, treatment and other

services provided, the patient's clinical course and clinical decision making
(including assessment-based treatment and service planning and periodic
reviews and modifications of the treatment/service plan)
 Purposes of Clinical Documentation—
Organization of Care
■ To serve as the basis for organization and continuity of care of the patient by the
practitioner:
– To record clinically meaningful information that the practitioner can later rely on to
refresh his or her memory of crucial events in treatment, the patient's response to
treatment and other services, problems experienced in treatment, key historical
facts and details of substantive collateral contacts
– To create a longitudinal record of the history of the patient’s complaints, symptoms,
comorbidities, assessments, diagnoses, treatment and other services provided,
clinical course, and response to treatment and other services so that the treating
practitioner and other practitioners who are, or who later become involved in
working with the patient can use this information to identify potential trends, guide
their assessment and guide their development and implementation of their
treatment/service plans
– To provide a basis for practitioner reflection and self-supervision on the patient's
evaluation, diagnoses, treatment and services, assessment-based
treatment/service plan, clinical course and progress
 Purposes of Clinical Documentation—
Continuity of Care
■ To serve as the basis for subsequent continuity of care of the patient by recording
for use by other practitioners who may serve the patient in the future clinically
meaningful data regarding the patient’s:
– Assessment, diagnoses, treatment and other services provided, clinical course,
progress and response to treatment and other services
– Assessment-based treatment and service plans and the periodic reviews and
modifications of those plans
– Trends, crises and problems in treatment, so that they may have sufficient data
based upon which they can provide meaningfully clinically informed continuity
of care to the patient;
 Purposes of Clinical Documentation—
Risk Management
■ For risk management purposes to protect against malpractice lawsuits and
professional discipline complaints, and to aid in defending effectively against any
such lawsuits or complaints (in this regard, be aware that if you didn’t document
something of importance in the patient’s clinical record and that becomes the
subject of contention in a legal or disciplinary proceeding against you, it can be
treated by a court or administrative body as if it did not happen or you missed it or
you ignored it or you did not address it, etc.,)
Purposes of Clinical Documentation—
Risk Management
– To document informed consent (i.e., for treatment, disclosure of information) and the nature and extent of the
professional relationship and of duty owed with regard to the patient
– To explain, detail and justify professional decision-making, problems encountered in working with the patient, and
the professional response to crises and other special or problem situations
– To record the details of supervision/consultation obtained in relation to the assessment and treatment of the
patient, particularly with regard to crises or other special or problematic situations that arise
– For supervisors (who are legally professionally responsible and accountable for the professional services
provided by their supervisees) to document each of their supervisory sessions, each of their contacts with the
patients whose care they are supervising, and their oversight of the assessments, treatment and other services
rendered by their supervisees under their supervision in order to enable them to defend the quality and
appropriateness of their supervision and the quality of their supervisee’s professional work against any
malpractice lawsuit or professional discipline complaint alleging negligent supervision or malpractice by them or
their supervisee
– To record information that will support the adequacy of the clinical assessment, the appropriateness of the
treatment/service plan and the application of professional skills and knowledge in the provision of professional
services
– To substantiate the treatment/services provided and the results of such treatment/services
 Purpose of Clinical Documentation--
Compliance
■ To comply with legal, regulatory and institutional requirements
– To ensure compliance with clinical documentation and recordkeeping
requirements imposed by federal and state (including licensing boards) laws,
regulations and rules
– To ensure compliance with clinical documentation and recordkeeping
standards set by specific accreditation programs (i.e., JCAHO) and by health
care institutions, facilities and agencies
– To fulfill clinical documentation and recordkeeping requirements of various
third-party payers (i.e. Medicare, Workmen's Compensation, Medicaid,
insurance, managed care plans);
 Purpose of Clinical Documentation—
Quality Assurance/Utilization Review
■ To facilitate quality assurance and utilization review
– To record professional activities, the process and substance of assessment, differential diagnosis, treatment and
service planning, clinical decision-making and the results of treatments and other services provided
– To document the appropriateness, clinical necessity and effectiveness of treatments and other services provided
– To substantiate the need for further assessment, testing, treatment and/or other services, or to support changes
in or termination of treatment and/or services
– To facilitate supervision, consultation and staff/professional development
– To help improve the quality of services by identifying problems with service delivery by providing data based upon
which effective preventative or corrective actions can be undertaken to improve and assure the quality of care
– To provide data for use in planning educational and professional development activities, policy development,
program planning and research in agency settings
– To provide data to guide choices of continuing professional education programs to attend, ongoing review and
revision of the organization and operation of the practitioner’s professional practice and research in private
practice settings
 The Role of Clinical Documentation in
Quality Assurance
■ Having to prepare proper clinical documentation serves an important role of helping
ensure quality patient care by making practitioners think about their patients, review and
reflect on their therapeutic interventions, consider the efficacy of their clinical work and
weigh alternative approaches to the care of their patients.

■ The capacity for professional self-reflection and self-appraisal of one's professional work
is essential to a practitioner’s professional development, to the maintenance of his or
her professional skills and to the provision of high quality clinical services.

■ Rather than viewing clinical documentation as a meaningless chore that consumes

precious time, practitioners should view it in this light, as a form of self-supervision that
is an essential element of their professional practice and of their provision of quality
clinical services.
 Purpose of Clinical Documentation--
Coordination
■ To facilitate coordination of professional efforts by fostering communication and
collaboration between members of the treatment team

– To ensure coordinated rather than fragmented treatment/service delivery

– To ensure appropriate utilization of team members from multiple disciplines in

order to bring to work collaboratively in an interdisciplinary/transdisciplinary
manner the particular competencies of team members from various disciplines
and/or who have specific specialties to maximize the quality of services to
patients.
 ELEMENTS OF GOOD CLINICAL
DOCUMENTATION—
Recording & Organization
■ Clinical documentation should be recorded and organized as follows:

– 1) Each page of a patient record should have the patient’s name clearly
printed or typewritten on the top.
– 2) ALL entries in the patient record should be signed (either in handwritten
form or electronic form) by the practitioner making the entry.
– 3) Entries in the patient record should be written contemporaneously with the
events they are documenting.
– 4) Each entry in a patient record should be dated the day it is written.
 ELEMENTS OF GOOD CLINICAL
DOCUMENTATION—
Recording & Organization
– 5. If an entry in a patient record documents an interview, therapy session, missed session,
any follow-up of the missed session, assessment or other substantive patient related
collateral contact (i.e.; with another treating practitioner, with a family member, with the
parents of a child who is in treatment) that took place earlier than the day the entry is
written, the entry should include clear documentation of the day the activity being
documented occurred.

– 6) Any materials or information received regarding a patient which are entered in the clinical
record should be dated and initialed on the day the information or material is initially
reviewed and placed in the patient record. Additionally, a progress note should be written to
document the review of the material or information and any action taken as a result of that
review.

– 7) All substantive collateral contacts with others relating to the patient and all referrals made
relating to the patient should be documented contemporaneously in the patient’s clinical
record. Timely follow-up on any referral made should be documented in the patient’s clinical
record.
 ELEMENTS OF GOOD CLINICAL
DOCUMENTATION—
Recording & Organization
8) The record should be kept neatly, in date order for each section, in at least the following sections:

a) basic contact and demographic information about the patient

b) intake information including demographic and contact

information about the patient

c) progress notes, initial and interval updates of treatment/service

plans and closing/termination summary

d) referrals made, tests requested, and the reports of consultations,

referrals or test results which are received
 ELEMENTS OF GOOD CLINICAL
DOCUMENTATION—
Recording & Organization
e) communications with other practitioners received or sent relating
to the patient

f) non-professional correspondence to or from the patient or from

non-professional collateral contacts

g) billing records including copies of bills provided to patients, claims

submitted to third-party payors, correspondence with patients
and third-party payors relating to billing and payments
ELEMENTS OF GOOD CLINICAL
DOCUMENTATION—
■
Recording & Organization
h. A chronological financial ledger by date:

– (1) of services rendered - with the following information for each service [including separate services
rendered on the same day]: date of service(s), description of service(s) with CPT [Current Procedural
Terminology] codes, if the charge for a service is based on time spent the amount of time spent, and
the charge(s) for the service(s)

– (2) of financial transactions with the following information, the date and amount of the financial
transaction, the nature of the transaction [payment, payment of coinsurance, denial of payment in
whole or in part by third-party payor, etc.], the source of the transaction [patient, parent or guardian of
patient, insurance or managed care third-party payor, etc.), write-off of charges and reason

– (3) Running outstanding balance

■ i. Documents relating to HIPAA compliance, informed consent for treatment documents, consents and
authorizations for use and/or disclosure of clinical information and records
 Elements of Good Clinical
Documentation - Writing
■ Clinical documentation should be written in a manner that is well organized and that
allows rapid location, recovery and utilization of clinical and other information about
the patient.

■ Writing good, useful clinical documentation requires thinking about and reflecting
on the event(s) being documented in the context of the patient’s history and
condition, the treatment and services being provided, and the patient’s
treatment/service plan.
 Elements of Good Clinical
Documentation - Writing
■ 1) Provides relevant information in appropriate detail

■ 2) Is organized with appropriate headings and logical progression

■ 3) Is thoughtful, reflecting the application of professional knowledge, skills and

judgement in the treatment/services provided

■ 4) Is appropriately concise

■ 5) Serves the purposes of clinical documentation

 Elements of Good Clinical
Documentation - Writing
■ 6) Uses relevant direct quotes from the patient and from other sources identified as such by
utilizing quotation marks

■ 7) Distinguishes clearly between facts, observations, hard data and opinions

■ 8) States the source(s) of the facts, observations, hard data, opinions and other information being
relied upon, and provides an assessment of the reliability of that material

■ 9) Is internally consistent

■ 10) Is written in the present tense, as appropriate

Biopsychosocial Model
Biopsycosocial Model

■ Developed by George L. Engel (American Psychiatrist—1977)

■ States that interactions between biological, psychological, and social factors

determine the cause, manifestation, and outcome of wellness and disease

■ Historically, popular theories like the nature versus nurture debate posited that any
one of these factors was sufficient to change the course of development. The
biopsychosocial model argues that any one factor is not sufficient; it is the interplay
between people's genetic makeup (biology), mental health and behavior
(psychology), and social and cultural context that determine the course of their
health-related outcomes.
Biological Influences on Health

– Many disorders have an inherited genetic vulnerability.

– The greatest single risk factor for developing schizophrenia, for example, is
having a first-degree relative with the disease (risk is 6.5%)
Psychological Influences on Health

■ Depression on its own may not cause liver problems, but a person with depression
may be more likely to abuse alcohol, and, therefore, develop liver damage.
Increased risk-taking leads to an increased likelihood of disease.
Social Influences on Health

■ Social factors include socioeconomic status, culture, technology, and religion. For
instance, losing one's job or ending a romantic relationship may place one at risk
of stress and illness. Such life events may predispose an individual to developing
depression, which may, in turn, contribute to physical health problems.

■ The impact of social factors is widely recognized in mental disorders like anorexia
nervosa (a disorder characterized by excessive and purposeful weight loss despite
evidence of low body weight). The fashion industry and the media promote an
unhealthy standard of beauty that emphasizes thinness over health. This exerts
social pressure to attain this "ideal" body image despite the obvious health risks.
Social Readjustment Scale
Culture as a Social Influence

■ Cultural factors

– Differences in the circumstances, expectations, and belief systems of different

cultural groups contribute to different prevalence rates and symptom
expression of disorders.

– For example, anorexia is less common in non-western cultures because they

put less emphasis on thinness in women.
Culture as a Social Influence

■ Culture can vary across a small geographic range, such as from lower-income to
higher-income areas, and rates of disease and illness differ across these
communities accordingly.

■ Culture can even change biology, as research on epigenetics is beginning to show.

Specifically, research on epigenetics suggests that the environment can actually
alter an individual's genetic makeup. For instance, research shows that individuals
exposed to over-crowding and poverty are more at risk for developing depression
with actual genetic mutations forming over only a single generation.
Maria
Example: Biomedical Model

■ Reason for visit: Maria complains of chest pain.

■ Presentation: The focus is on physical causes of disease. The clinician will ask few
questions on recent diet, pain history, and familial incidence, however, empirical
signs and symptoms of myocardial infarction are considered paramount.
■ Diagnosis: The clinician will recommend objective lab tests and monitor vital signs
(i.e. temperature, pulse, and blood pressure) that would form the sole basis of any
diagnosis.
■ Therapy: The clinician would refer Maria to a doctor to prescribe a medicinal plan for
the patient based on biological etiology and pathogenesis.
Example: Biopsychosocial Model

■ Reason for visit: Maria complains of chest pain.

■ Presentation: The aim is to ascertain psychosocial and physical processes that may
cause the chief complain, chest pain. The clinician may ask for a history of recent
life stressors and behaviors.
■ Diagnosis: Based on a combination of psychological factors and standard lab tests,
the clinician will form a diagnosis.
■ Therapy: The clinician discusses the available interventions with special attention to
behaviors and lifestyles that could influence her pain and adherence to the
treatment plan. Maria is involved in formulating and implementing the plan, and
maintains a supportive relationship with the clinician.
Mental Status Exam
What is the Mental Status Examination
(MSE)?

■ May be viewed as the psychological equivalent of the physical exam

■ A snapshot of the patient at a given time

■ Observations noted throughout the interview become part of the MSE, which begins
when the clinician first meets the patient. Information is gathered about the
patient’s behaviors, thinking, and mood.
George
George

■ A 55-year-old man presented with recent complaints of sadness and fear of being
alone. He also expressed thoughts about death. As he presented his concerns, he
rambled to unrelated topics and seemed to lose track of the interviewer’s questions.
During the formal inquiry he was able to recall only 1 of 3 objects he was asked to
memorize and made several mistakes in serial subtractions of 7 from 100. Specific
questioning about suicidal wishes and actions revealed that he had overdosed with
aspirin 1 month earlier and still experienced suicidal thoughts and wishes to die.
George

■ The cognitive tests were compatible with mild dementia, and the differential
diagnosis included major depression.

■ Further work-up and treatment supported this diagnosis.

■ Cognitive functioning improved with antidepressants.

 Is the MSE a separate part of the
patient evaluation?

■ No. The MSE must be interpreted along with the presenting history, physical exam,
and lab and other reports. Separate interpretation makes you vulnerable to
erroneous conclusions.

■ Collateral information from families and friends may be invaluable to confirm or

supply missing data.
Jane
Jane

■ A 27-year-old woman presented to the psychiatric emergency department with

somewhat grandiose behavior, pressured speech, irritability, and psychomotor
agitation. The initial diagnostic impression was bipolar disorder, manic or drug
induced mania. The patient denied drug abuse. However, questioning her wife
uncovered a history of substance abuse, and laboratory evaluation revealed the
presence of amphetamine metabolites. The correct diagnosis was amphetamine-
induced mood disorder.
What key factors should be considered
along with the MSE?
– To assess properly the patient’s mental status, it is important to have some
understanding of the patient’s social, cultural, and educational background.

– What may be abnormal for someone with more intellectual ability may be normal
for someone with less intellectual ability.

– Patients for whom English is a second language may have difficulty understanding
various components of the MSE.

– Age may be a factor. In general, patients over the age of 60 years tend to do less
well on the cognitive elements of the MSE. Often this is related to less education
rather than to aging alone.
Major Components of the MSE

■ Appearance
■ Motor activity
■ Speech
■ Affect
■ Thought content
■ Thought process
■ Perception
■ Intellect
■ Insight
Major Components of the MSE

■ Memory can be assessed by asking about news events, sports, television shows, or
recent meals.
■ Long-term memory can be assessed by using past events confirmed by family
members and also by repeating names of historical figures, such as presidents of
the U.S.
■ Language ability can be assessed by asking patients to explain similarities and
differences between common objects (e.g., tree-bush, car-plane, air-water).
■ Thinking processes can be assessed by asking patients to explain common proverbs
(ie—”two wrongs don’t make a right”) with which they are familiar.
Does the MSE Establish Competence?

■ No. Competence relates to patients’ ability to make reasonable decisions for themselves
and others. Such decisions include ability to provide food and shelter, to manage money,
and to participate in activities such as deciding a course of medical care.
■ Patients who score well on an MSE may have still deficits in understanding or completing
common tasks of daily living and may, therefore, not be competent.
■ Among a population with a probable diagnosis of Alzheimer’s disease, 50% of patients
had no difficulty with the MSE but had significant trouble with basic tasks such as coping
with small sums of money or finding their way around familiar streets.
■ The MSE is only one component needed to assess competency. Medical condition,
current ability for self-care, and corroborating information from family or friends must be
taken in consideration.
 Mental Status Exam

Mini Mental Status Exam

You’re a Good Man Charlie Brown Lunch Time
Screening
 Screening & Assessment for ALL
Disorders is Necessary Because...
■ Having one disorder increases the risk of developing another
disorder;
■ The presence of a second disorder makes treatment of the
first more complicated;
■ Treating one disorder does NOT lead to effective
management of the other(s);
■ Treatment outcomes are poorer when co-occurring disorders
are present.

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 Know Your Limitations….

■ Counselors should understand the limitations of their

licensure or certification authority to diagnose or assess
mental disorders. Generally, however, collecting
screening & assessment information is a legitimate and
legal activity even for unlicensed providers, provided
that they do not use diagnostic labels as conclusions or
opinions about the client

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 Basic Screening & Assessment Must
Address:
■ Medical issues (including physical disability and
sexually transmitted diseases)
■ Cultural issues
■ Gender-specific issues
■ Sexual orientation issues
■ Legal issues

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Healing for Adults, Youth and Families
 Screening
■ Screening is a formal process of testing to determine whether a client does
or does not warrant further attention at the current time in regard to a
particular disorder.
■ The screening process seeks to answer a “yes” or “no” question: Does the
substance abuse (or mental health) client being screened show signs of a
possible mental health (or substance abuse) problem?
■ Note that the screening process does not necessarily identify what kind of
problem the person might have or how serious it might be, but determines
whether or not further assessment is warranted.

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Screening Protocol

Screening processes always should define a protocol for:

– Determining which clients screen positive
■ Screening Tool
■ Cut-off Scores

– Ensuring that those clients receive a thorough assessment

■ Who Performs the Assessment
■ Documentation

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Specific Screening Areas

■ Suicidality
■ Trauma
■ Violence
■ Addiction
– Chemical
– Process
■ Mental Health Disorders
– Depression
– Anxiety
– Post-Traumatic Stress
Specific Screening Areas

■ The counselor should know what immediate onsite and offsite resources are available to
help with someone identified as positive in a screening.

■ Establish standardized protocols and staff training around screening, assessment,

intervention and/or triage:
■ Who asks?
■ What is asked?
■ When is this done?
■ When does this take place?
■ How is this documented?
■ What is done with the results?

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 Suicidality
■ All clients in rehab or mental health facilities should be screened.

■ The counselor should know his or her own skills and limitations in engaging, screening,
assessing and intervening with suicidal clients. Work out these issues before an
emergency.

■ Providers are advised to develop clear answers to the following questions:

– Do you or your agency have the knowledge, tools, skills,
and personnel for crisis stabilization and/or
ongoing work with suicidal clients?
– How suicidal can clients be and still be retained in your practice or agency?
– What about suicidality that emerges later in treatment or in
conjunction with a relapse?
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It is best to ask clients about suicide
directly
■ Research does not support that asking about
suicide will put that idea in their mind

■ Questions could include:

– “In the past, have you ever been suicidal or made a suicide attempt?”

– “Do you have any of those feelings now?”

IS PATH WARM

■ I = Ideation
■ S = Substance abuse
■ P = Purposelessness
■ A = Anxiety
■ T = Trapped
■ H = Hopelessness
■ W = Withdrawal
■ A = Anger
■ R = Recklessness
■ M = Mood changes

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Suicidality

■ If a client is screened positive for suicidality, he or she should not be left alone until
someone appropriate can determined the level of risk.

■ Suicide “contracts” are written statements in which the person who is suicidal states
that he will not kill himself, but rather call for help, go to an emergency room if he
becomes suicidal. These contracts are not effective as the sole intervention for a
client who is suicidal. While such contracts often help to make the client and
therapist less anxious about a suicidal condition, studies have never shown these
contracts to be effective at preventing suicide. What good contracts really do is help
to focus on the key elements that are most likely to keep clients safe, such as
agreeing to remove the means a client is most likely to use to commit suicide.
Trauma Screening

■ Regardless of the setting, all clients should be screened for past and present
victimization and trauma.

■ In screening for a history of trauma or in obtaining preliminary symptoms of post-

traumatic stress, it can be damaging to ask the client to describe traumatic events
in detail.

■ All questions should avoid “retraumatizing” the client.

To screen, it is important to limit questioning to very
brief and general questions:

• “Have you ever experienced childhood physical

abuse?
• Have you ever experienced sexual abuse?
• Have you ever experienced a serious accident?
• Have you ever experienced violence or the threat of
it?
• Have there been experiences in your life that were
so traumatic they left you unable to cope with day-
to-day life?
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Violence Screening Questions

■ 1. What kinds of things make you mad? What do you do when you get mad?
■ 2. What is your temper like? What kinds of things can make you lose your temper?
■ 3. What is the most violent thing you have ever done and how did it happen?
■ 4. What is the closest you have ever come to being violent?
■ 5. Have you ever used a weapon in a fight or to hurt someone?
■ 6. What would have to happen in order for you to get so mad or angry that you
would hurt someone?
■ 7. Do you own weapons like guns or knives? Where are they now?
 CAGE
Substance Abuse Screening
1. Have you ever felt you should cut down on your drinking or drug use?

2. Have people annoyed you by criticizing your drinking or drug use?

3. Have you ever felt bad or guilty about your drinking?

4. Have you ever had a drink or drug first thing in the morning to steady your nerves or
get rid of a hangover (eye-opener)?
Mental Health Screening Form-III
Mental Health Screening Form III

■ Instructions: In this program, we help people with all their problems, not just their
addictions. This commitment includes helping people with emotional problems. Our
staff is ready to help you to deal with any emotional problems you may have, but we
can do this only if we are aware of the problems. Any information you provide to us
on this form will be kept in strict confidence. It will not be released to any outside
person or agency without your permission. If you do not know how to answer these
questions, ask the staff member giving you this form for guidance. Please note, each
item refers to your entire life history, not just your current situation, this is why each
question begins –“Have you ever ....”
Mental Health Screening Form III

■ 1) Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or

counselor about an emotional problem
■ 2) Have you ever felt you needed help with your emotional problems, or have you
had people tell you that you should get help for your emotional problems?
■ 3) Have you ever been advised to take medication for anxiety, depression, hearing
voices, or for any other emotional problem?
■ 4) Have you ever been seen in a psychiatric emergency room or been hospitalized
for psychiatric reasons?
Mental Health Screening Form III

■ 5) Have you ever heard voices no one else could hear or seen objects or things
which others could not see?
■ 6) a) Have you ever been depressed for weeks at a time, lost interest or pleasure in
most activities, had trouble concentrating and making decisions, or thought about
killing yourself? b) Did you ever attempt to kill yourself?
■ 7) Have you ever had nightmares or flashbacks as a result of being involved in some
traumatic/terrible event? For example, warfare, gang fights, fire, domestic violence,
rape, incest, car accident, being shot or stabbed?
Mental Health Screening Form III

■ 8) Have you ever experienced any strong fears? For example, of heights, insects,
animals, dirt, attending social events, being in a crowd, being alone, being in places
where it may be hard to escape or get help?
■ 9) Have you ever given in to an aggressive urge or impulse, on more than one
occasion, that resulted in serious harm to others or led to the destruction of
property?
■ 10) Have you ever felt that people had something against you, without them
necessarily saying so, or that someone or some group may be trying to influence
your thoughts or behavior?
Mental Health Screening Form III

■ 11) Have you ever experienced any emotional problems associated with your sexual
interests, your sexual activities, or your choice of sexual partner?
■ 12) Was there ever a period in your life when you spent a lot of time thinking and
worrying about gaining weight, becoming fat, or controlling your eating? For
example, by repeatedly dieting or fasting, engaging in much exercise to compensate
for binge eating, taking enemas, or forcing yourself to throw up?
■ 13) Have you ever had a period of time when you were so full of energy and your
ideas came very rapidly, when you talked nearly non-stop, when you moved quickly
from one activity to another, when you needed little sleep, and believed you could do
almost anything?
Mental Health Screening Form III

■ 14. Have you ever had spells or attacks when you suddenly felt anxious, frightened,
uneasy to the extent that you began sweating, your heart began to beat rapidly, you were
shaking or trembling, your stomach was upset, you felt dizzy or unsteady, as if you would
faint?
■ 15) Have you ever had a persistent, lasting thought or impulse to do something over and
over that caused you considerable distress and interfered with normal routines, work, or
your social relations? Examples would include repeatedly counting things, checking and
rechecking on things you had done, washing and rewashing your hands, praying, or
maintaining a very rigid schedule of daily activities from which you could not deviate.
■ 16) 1.Have you ever lost considerable sums of money through gambling or had problems
at work, in school, with your family and friends as a result of your gambling?
■ 17) Have you ever been told by teachers, guidance counselors, or others that you have a
special learning problem?
Assessment
Assessment is a process for defining the nature of
the problem(s) and developing specific treatment
recommendations for addressing the problem(s).

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 Purposes of Basic Assessment

■ Provides key information for treatment matching & treatment planning

■ Offers a structure to obtain the following:
– Basic Demographic & historical information
– Identification of established or probable diagnosis and associated impairments
– General strengths & problem areas
– Stage of change for both SU & MH
– Preliminary determination of the severity of COD as a guide to final level of care
determination

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Purposes of Basic Assessment

■ Background—family, trauma history, history of domestic violence (either as a

batterer or as a battered person), marital status, legal involvement and financial
situation, health, education, housing status, strengths and resources, and
employment

■ Substance use—age of first use, primary drugs used (including alcohol, patterns of
drug use, and treatment episodes), and family history of substance use problems

■ Mental health problems—family history of mental health problems, client history of

mental health problems including diagnosis, hospitalization and other treatment,
current symptoms and mental status, medications, and medication adherence

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Purposes of Basic Assessment

■ Detailed chronological history of past mental symptoms, diagnosis, treatment, and

impairment, particularly before the onset of substance abuse, and during periods of
extended abstinence

■ Detailed description of current strengths, supports, limitations, skill deficits, and

cultural barriers related to following the recommended treatment regimen for any
disorder or problem

■ To determine stage of change for each problem, and identify external contingencies
that might help to promote treatment adherence.

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Assessment of the client with COD is an ongoing
process that should be repeated over time to
capture the changing nature of the client’s
status.

Assessments must be continuous and monitored

and revised as the client moves through recovery

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All assessments should include routine
procedures for identifying and contacting any
family and other collaterals who may have
useful information to provide.

Process of seeking such information must be

carried out strictly in accordance with
applicable guidelines and laws regarding
confidentiality and with the client’s
permission.
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All assessment must include some specific attention to
the individual’s current strengths, skills, and supports,
both in relation to general life functioning, and in relation
to his or her ability to manage either mental or substance
use disorders.

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Questions might focus on:

• Talents and interests

• Areas of educational interest and literacy;
vocational skill, interest, and ability, such as
vocational skills, social skills, or capacity for
creative self-expression
• Areas connected with high levels of motivation to
change, for either disorder or both
• Existing supportive relationships, treatment, peer,
or family, particularly ongoing mental disorder
treatment relationships
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Questions might focus on:
• Previous mental health services and addiction
treatment successes, and exploration of what
worked
• Identification of current successes: What has the
client done right recently, for either disorder?
• Building treatment plans and interventions based
on utilizing and reinforcing strengths, and extending
or supporting what has worked previously
Questions to Ask…

• How are your substance abuse and mental health

problems defined by your parents? Peers? Other
clients?
• What do they think you should be doing to remedy
these problems?
• How do you decide which suggestions to follow?
• In what kinds of treatment settings do you feel most
comfortable?
• What do you think I (the counselor) should be doing to
help you improve your situation?
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Questions to Ask…

■ What does the client want?

■ What is the treatment contract?
■ What are the immediate needs?
■ What are the diagnoses?
■ Identify which assessment dimensions are most severe to
determine treatment priorities.
■ Choose a specific priority for each medium/severe dimension.

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Questions to Ask…

■ What specific services are needed to address these

priorities?
■ What “dose” or intensity of services is needed?
■ Where can these services be provided in the least
intensive, but safe, level of care or site of care?
■ How will outcomes be measured?
■ What is the progress of the treatment plan and
placement decision?
The Clinician’s Role

■ Highly publicized acts of violence by people with mental illness affect more than
public perception.
■ Clinicians are under pressure to assess their patients for potential to act in a violent
way.
■ Although it is possible to make a general assessment of relative risk, it is impossible
to predict an individual, specific act of violence, given that such acts tend to occur
when the perpetrator is highly emotional. During a clinical session, the same person
may be guarded, less emotional, and even thoughtful, thereby masking any signs of
violent intent. And even when the patient explicitly expresses intent to harm
someone else, the relative risk for acting on that plan is still significantly influenced
by the following life circumstances and clinical factors.
The Clinician’s Role

■ Although, in most settings, the majority of clients do not pose a significant risk for
violence, an inquiry into aggressive and violent behavior should be made with each
new client

■ A client’s inability to maintain her composure or control her anger and irritability in
the context of a clinical interview may say much about her ability in real life settings
The Clinician’s Role

■ Clinicians are encouraged to think about violence risk in conditional terms (i.e., “If . .
. , then . . . .”) and offer opinions in this way when they are required
■ The conceptualization of violence risk as something that can change over time,
across conditions, or in response to various interventions
■ The risk assessment perspective, as compared to “dangerousness prediction” and
its associated language and conceptualization, facilitates incorporation of
information about violence risk into treatment planning.
Key Questions in a Suicide/Violence Risk Review

What is wrong?
• Personal narrative about how bad things are and the nature of the
problem(s)
• Personal construction of reasons for suicide/violence
• Personal measure of psychological pain and suffering

Why now?
• Elements of the current crisis
• History of real or imagined losses or rejections
• Sudden and unacceptable changes in life circumstances; for example, the
client just received a serious or terminal diagnosis, relapse, onset of
possible symptoms (e.g., sleeplessness)

With what?
• The means of suicide/violence under consideration
• Access to the means selected

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 Key Questions in a Suicide/Violence
Risk Review
Where and when?
■ Possible location and timing of a suicide/violence Degree of planning
■ Possible anniversary phenomena

When and with what in the past?

■ Past history of suicidal/violent behavior
■ Past history of intense suicidal/violence ideation and/or planning
■ Whether rescue was avoided
■ Timing of past attempts
■ Social response to past attempts
■ Potential protective factors
■ Comparison of current method versus old method
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 Key Questions in a Suicide/Violence
Risk Review

Who’s involved?
■ Others who may know or be involved
■ Persons who may or may not be helpful in managing the client
■ Names of potentially helpful third parties
■ Possible presence of a suicide pact or murder-suicide plan

Why not now?

■ One or more protective factors (reasons for living)
■ Spiritual or religious prohibitions

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Beck’s Suicide Inventory
Suicide Risk Assessment Tool
Trauma Assessment Tool
Diagnosis

■ Principle #1: Diagnosis is established more by history than by

current symptom presentation. This applies to both mental
and substance abuse disorders.

■ If there is evidence of a disorder but the diagnosis/treatment

recommendations are unclear, the counselor should
immediately begin the process of obtaining this information
from collaterals.
Sally
 Sally

■ EXAMPLE #1: Sally comes into you office under the influence of alcohol, it is
reasonable to Substance Use Disorder, but the only diagnosis that can be made
based on that circumstance is “alcohol intoxication.” It is important to note that this
warrants further investigation; on the one hand, false positives can occur, while on
the other, detoxification may be needed.

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Brady
 Brady

■ EXAMPLE #2: Brady comes into your office and has not had a drink in 10 years,
attends Alcoholics Anonymous (AA) meetings three times per week, and had four
previous detoxification admissions, a diagnosis of Substance Use Disorder (in
remission at present) can be made. Moreover, you can predict that 20 years from
now that client will still have the diagnosis of Substance Use Disorder since this is a
lifetime diagnosis.
Valerie
 Valerie

■ EXAMPLE 3: If Valerie comes into your office and says she hears voices (whether or
not she is sober currently), no diagnosis should be made on that basis alone. There
are many reasons people hear voices. They may be related to substance-related
syndromes (e.g., substance-induced psychosis, which includes the experience of
hearing voices that the client knows are not real, and that may say things that are
distressing or attacking—particularly when there is a trauma history—but are not
bizarre).

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Oscar
 Oscar

■ EXAMPLE 4: If Oscar states he has heard voices, though not as much as he used to,
that he has been clean and sober for 4 years, that he remembers to take his
medication most days though every now and then he forgets, and that he had
multiple psychiatric hospitalizations for psychosis 10 years ago but none since, then
Oscar clearly has a diagnosis of psychotic illness (probably schizophrenia or
schizoaffective disorder). Given his continuing symptoms while clean and sober and
on medication, it is quite possible that the diagnosis will persist.
Diagnosis

■ Principle #2: It is important to document prior

diagnoses and gather information related to current
diagnoses, even though a counselor may not be
licensed to make a mental disorder diagnosis.
Diagnoses established by history should not be
changed at the point of initial assessment. If the
clinician has a suspicion that a long-established
diagnosis may be invalid, it is important that he
or she takes time to gather additional
information, consult with collaterals, get more
careful and detailed history and develop a better
relationship with the client before
recommending diagnostic re-evaluation.

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Diagnosis

■ Principle #3 : For diagnostic purposes, it is almost

always necessary to tie mental symptoms to specific
periods of time in the client’s history, in particular
those times when active substance use disorder was
not present.

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• Inquire whether any mental symptoms or treatments
identified in the screening process were present
during periods of 30 days of abstinence or longer, or
were present before onset of substance use.

• Determination of both current and baseline

functional impairment contributes to identification of
the need for case management and/or higher levels
of support. This step also relates to the
determination of level of care requirements.

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Assessment Summary
 The Documentation of a Proper Initial
Assessment
■ 1) Identification of the referral source(s), gathering information about the
background and reasons for the referral and assessing the patient's response to
and expectations with regard to the referral;

■ 2) Defining the presenting problem(s) and what the patient wants to accomplish in
treatment, both in the patient's own words using appropriate quotes (identified by
using quotation marks), as well as in terms of the practitioner's perception of the
presenting problem(s) and needs of the patient;
 The Documentation of a Proper Initial
Assessment
■ 3) Detailing the history and clinical course of presenting problem(s) and the details
of treatment or services the patient has sought or received to deal with those
problems in the past (either in the long term or in the immediate past);

■ 4) Gathering and documenting relevant history from the patient and from collateral
sources, in appropriate detail, by topic, identifying the sources of such historical
information and assessing the reliability of the information, regarding:
 The Documentation of a Proper Initial
Assessment
■ a) Family history including a list of family members in families of origin and procreation
and basic demographic information about them (i.e., age, birthplace, education,
occupation, age, and cause of death if applicable), a brief description about their
relationship with the patient, marital history, and any family history of mental,
neurological, substance abuse/alcoholism or serious medical problems;

■ b) Medical history including details of serious or chronic ailments, hospitalizations,

serious physical trauma and/or surgery, allergies or adverse drug reactions; any physical
disabilities and how the patient has and/or is coping with them; any chronic medications
and all current medications including OTC drugs, supplements, herbs and other
alternative treatments, and information about their relationships and feelings about past
and current treating practitioners;
 The Documentation of a Proper Initial
Assessment
■ c) Psychiatric history including details of mental health symptoms, diagnoses and
treatments, hospitalizations (including whether voluntary or not), what precipitated
or triggered the symptoms, treatment or hospitalization, and the patient’s response
to prior mental health treatment (including response to and side effects of particular
psychotropic medications that have been prescribed), prior psychotherapy and/or
psychopharmacotherapy and the patient’s response to and feelings about
psychotherapy and/or psychopharmacotherapy; history of treatment compliance
and non-compliance (if patient left treatment, why he or she did so and with what
results), details of the degree of the patient’s mental disability and how the patient
is coping with this; and information about their relationships and feelings about past
and current treating mental health practitioners;
 The Documentation of a Proper Initial
Assessment
■ d) History of alcohol and other substance abuse and alcoholism and substance abuse
treatment including, for each substance of abuse, including alcohol, the substance, the
first and most recent use of the substance, the route(s) of use, the amount used/time
period (i.e., $10 of crack/day, five 40oz cans of beer/weekend), the frequency of use
(i.e., steady on a daily basis, binging once every three of four weeks for one to three
days) the duration of use, any significant periods of abstinence (including how these
were achieved and why they ended), the social context of the substance abuse (i.e.,
alone, sharing with others, only at parties), identified triggers for the substance abuse,
treatment programs attended (which ones, when and for how long, what the patient liked
and disliked about the program, what the patient felt that he or she accomplished and
did not accomplish in the program, and whether the patient completed the program
successfully, if not, why), and the biopsychosocial impact of the substance abuse on the
patient and his or her significant others;
 The Documentation of a Proper Initial
Assessment
■ e) Child and adolescent developmental history including family and peer group
relationships, home life, socio-economic status, schooling, parenting and discipline,
type of neighborhood and housing, learning disabilities and other developmental
delays (in children and young adolescents a more detailed developmental history is
usually indicated);
■ f) Educational history including level of academic achievement, academic strengths
and weaknesses, relationships with teachers, history of being denied regular
promotion, placement in special education or other special educational programs,
school behavior including any suspensions, expulsions or school transfers;
 The Documentation of a Proper Initial
Assessment
■ g) History of occupational training/skills and work history including significant
employment, work related difficulties, how the patient views his or her work, the
patient’s career goals, general salary information and adult economic status;
■ h) History of interpersonal relationships including the nature and extent of peer
group relationships, marriages and other close relationships over the life span, what
has kept or keeps these relationships functioning, why and how these relationships
end, the patient’s reactions and feelings about the end of close interpersonal
relationships, the nature and type of any significant interpersonal problems the
patient has had or is having;
 The Documentation of a Proper Initial
Assessment
■ i) History of past and current social support systems including the nature and
impact of these or the lack of these on the patient’s development and functioning;
■ j) Juvenile and criminal justice history including the nature of any arrests,
convictions and any sentences imposed, and history of patterns of antisocial
behavior;
■ k) History of sexual relationships or psychosexual problems and issues including
sexual orientation issues and any sexual dysfunction;
■ l) History of religious affiliation and practices and issues relating to religion;
 The Documentation of a Proper Initial
Assessment
■ m) Spirituality (aside from religion) including the values, thoughts, emotions, motivations,
needs, dreams, experiences, assumptions and relationships that make the person a
unique individual, and provide him or her with the vitality, drive and determination to
develop and function as a fully actualized person;
■ n) Social issues his or her functioning in relation to other persons and his or her
environment including, but not limited to interpersonal and social relatedness, skills and
capacity; behavioral responses to environmental, mental and emotional events and
stimuli; responsiveness to the environment and to other persons; adaptive functioning
and behavior; stress and frustration tolerance and impulse control; linguistic and
communicative functioning; social judgement; and the influences of age, culture,
customs, disability, discrimination, economic factors, gender, geographic and other
environmental factors, health status, illness, injury, loss, national origin, pain and
suffering, politics, race and religion his or her development and functioning; and
 The Documentation of a Proper Initial
Assessment
■ o) History of physical, emotional or sexual abuse or other victimization including
where and when these occurred, the patient’s view of the impact of these on his or
her life, whom the patient told about these events and the response of people who
learned about these occurrences.
Treatment Plans
Treatment Plans

■ Road map to follow in treatment

■ No 2 road maps should be the same—everybody’s

journey is different

■ Must be fluid
Treatment Plans

■ Develop a Problems List

– Must be evidenced by signs and symptoms

– Must be measurable

– “as evidenced by” or “as indicated by”

Treatment Plans

■ Problem 1: Inability to maintain sobriety outside of a

structured facility
– As evidenced by: Blood alcohol level of .23 As
evidenced by: The patient’s family report of daily
drinking
– As evidenced by: Alcohol withdrawal symptoms As
evidenced by: Third DWI
– As evidenced by: History of third treatment for
addiction
Treatment Plans

– Problem 2: Depression
■ As evidenced by: Hamilton Depression Rating
Scale score of 29
■ As evidenced by: Psychological evaluation
■ As evidenced by: Patient’s two suicide
attempts in the past 3 months
■ As evidenced by: Depressed affect
Treatment Plans

■ Problem 3: Acute alcohol withdrawal

– As evidenced by: Coarse hand tremors
– As evidenced by: Blood pressure 160/100, pulse
104
– As evidenced by: Restless pacing; self-report of
strong craving
– As evidenced by: Profuse sweating; mild visual
disturbances
Treatment Plans

■ Develop Goals

– Brief clinical statement of the condition you expect to

change in the patient

– More than elimination of pathology

– Directed toward patient learning new and more functional

methods of coping
Treatment Plans

■ Instead of: The patient will stop drinking.

– Use: The patient will develop a program of recovery

congruent with a sober lifestyle. (The patient is
learning something different.)

– Use: The patient will learn to cope with stress in an

adaptive manner.
Treatment Plans

■ Instead of: The patient will stop negative self-talk. (The patient does
not learn something different or use something differently; the
patient just avoids something that he or she already knows.)

– Use: The patient will develop and use positive self-talk. (Now
the patient learns something different that is incompatible with
the old behavior.)

– Use: The patient will develop a positive self-image. (The patient

learns something new and more adaptive.)
Treatment Plans

■ Examples of Goals

– 1. The patient will learn the skills necessary to

maintain a sober lifestyle.
– 2. The patient will learn to express negative feelings
to his or her spouse.
– 3. The patient will develop a positive commitment to
sobriety.
Treatment Plans

– 4. The patient will develop a healthy diet and

begin to gain weight.
– 5. The patient will learn how to tolerate
uncomfortable feelings without using chemicals.
– 6. The patient will learn to share positive feelings
with others.
– 7. The patient will develop the ability to ask for
what he or she wants.
Treatment Plans

– 8. The patient will develop the ability to use anger

appropriately.
– 9. The patient will sleep comfortably on a regular
basis.
– 10. The patient will learn healthy communication
skills
 Treatment Plans
■ Develop Objectives

– A specific skill that patient must acquire to achieve a

goal

– Must be measurable
Treatment Plans

■ Goals usually can’t be seen; objective can been

seen.
– Can you see the patient read about Step One in
the Alcoholics Anonymous book (2001)? Yes.
(Objective)
– Can you see the patient understand the illness of
addiction? No. (Goal)
– Can you see the patient gain insight? No. (Goal)
– Can you see the patient complete the Step One
Treatment Plans

■ Can you see the patient improve his or her self-esteem?

■ Can you see the patient keep a daily record of his or

her dysfunctional thinking?

■ Can you see the patient share his or her feelings in

group?
Treatment Plans

■ Goal A: The patient will develop a program of

recovery congruent with a sober lifestyle, as
evidenced by:

– 1. The patient will share in the Individual

Assignments group three times when he or she
tried to stop drinking but was unable to stay
sober.
Treatment Plans

■ Goal B: The patient will learn to use assertiveness skills, as

indicated by:

– 1. The patient will discuss the assertive formula and will

role-play three situations where he or she acts assertively.

– 2. The patient will keep an assertiveness log and will

share the log with the counselor daily. 3. The patient will
practice assertiveness skills in interpersonal group.
Treatment Plans

■ Develop Interventions

– What you do to help the patient complete the

objective

– Must be measurable

– At least 1 intervention for every objective

Treatment Plans

– Intervention: Assign the patient to write a list of five

negative consequences of his or her drug use.
*Responsible professional: ____________________

– Intervention: In a conjoint session, have the patient

share the connection between drinking and
marijuana use.
*Responsible professional: ____________________
Treatment Plans

– Intervention: In group, encourage the patient to

share his or her anxious feelings.
*Responsible professional: ____________________

– Intervention: Have the patient develop a personal

recovery plan that includes all of the activities that
he or she plans to attend.
*Responsible professional: ____________________
Treatment Plan Samples
Treatment Plan Updates
Treatment Plan Updates

■ Problem 1: Patty continues on her Valium come-

down schedule. She has reported only mild
withdrawal symptoms. She is sleeping well. She
continues to be mildly restless. She was encouraged
to increase her level of exercise to 20 minutes daily.
Treatment Plan Updates

■ Problem 2: Patty has completed her chemical use

history and Step One exercise. She shared in
interpersonal group her powerlessness and
unmanageability. She was open in group, and she
verbalized that she has accepted her disease of
addiction. She was somewhat more reluctant to accept
her problem with Valium, but the group did a good job of
explaining cross-tolerance. The patient should complete
the cross-tolerance exercise and report her findings to
the group
Treatment Plan Updates

■ Problem 3: The patient continues to take her iron

supplement. Her hemoglobin is within normal limits.

■ Problem 4: The patient is over her cold. Problem 4 is

completed.
Treatment Plan Updates

■ Problem 5: The patient has written a letter to her

mother and father describing how she felt about her
childhood. The patient shared her letter in group,
and she was surprised to find out that many of the
other patients had similar experiences. The patient
stated that she is feeling more comfortable sharing
in group, and she appears to be gaining confidence
in herself. Patty met with her counselor, and the
counselor encouraged Patty to accept her new
AA/NA group as the healthy family that she never
Treatment Plan Updates

■ Problem 6: Patty is working on the relationship skills

exercise. She has been practicing asking for what
she wants. It is still very difficult for her to share
some of her feelings, particularly her anger, in group.
When she shares her anger, she tends to feel guilty.
Treatment Plan Updates

■ Problem 7: Patty completed the honesty

exercise and the chemical use history that
opened her eyes to how dishonest she has
been. Patty made a contract with her group to
be honest and asked the patients to confront
her if they felt that she was being dishonest.
Patty is keeping a daily log of her lies and
when she is tempted to lie. She has been able
Treatment Plan Updates

■ Problem 8: Patty is working on the assertiveness

skills exercise. She is practicing the assertive
formula. She tends to feel guilty when she says no,
but she is getting better at it. She will say no to
someone five times a day for 3 days and keep a log
of how she feels about each situation.
Progress Notes
Sheldon’s Psychotherapy Session
Progress Notes

■ Legal and ethical standards clearly state that therapists must maintain some kind of
record of the treatment they provide

■ The Documentation Function of Progress Notes

In the simplest terms, progress notes are brief, written notes in a patient’s treatment
record, which are produced by a therapist as a means of documenting aspects of his
or her patient’s treatment. Progress notes may also be used to document important
issues or concerns that are related to the patient’s treatment.
Progress Notes

■ The first function or purpose of a progress note is to record services provided by a

staff member. Progress notes are the primary source of data indicating that a
service was delivered.

■ The second function of a progress note is to document the course of treatment; i.e.,
progress or lack thereof related to a treatment intervention. Both functions of the
progress note are essential elements of evidence based practices.
Progress Notes

■ Good progress notes begin with effective treatment planning. If more work is given
to the proactive development of an effective treatment intervention, less work will be
needed in documenting those services.

■ Thorough and comprehensive treatment planning leads to easy documentation in

progress notes, whereas poorly developed treatment planning leads to extensive
documentation in progress notes (or worse, incomplete or unclear documentation of
services).
Progress Notes

■ Content, length and complexity of progress notes should vary, depending upon the
particular therapy session. In other words, an event that transpires in a given
therapy session may be especially critical or noteworthy, in comparison to another
session.

■ Progress notes are brief, written notes that are utilized to document a patient’s
treatment and various related issues, including treatment planning, documenting
the necessity of treatment and demonstrating the appropriateness, competency and
yes, hard work of the therapist.
 Documenting Competent Treatment

■ The treatment record is a formal recording of the assessment and treatment

rendered to a patient by his/her therapist. As one component of the patient’s
treatment record, progress notes allow a therapist to describe his or her work with a
patient.

■ Without progress notes, it would be difficult, if not impossible, for a therapist to

create a health care record that accurately reflects his or her sound clinical
judgment, the standards of the profession, and the nature of the services being
rendered. Furthermore, progress notes provide a therapist with an opportunity to
document his or her exercise of judgment in dealing with complex and challenging
treatment scenarios.
 Documenting Competent Treatment

■ Progress notes may reflect a therapist’s ongoing

efforts to assess and manage his or her patient’s
symptoms, or demonstrate his or her therapeutic
skill in responding to complex risk factors. In
addition, should a therapist’s conduct be challenged
by the patient or by the Board, progress notes may
help to establish that his or her conduct was ethical
and lawful.
 Documenting Treatment Necessity

■ Progress notes provide evidence of the patient’s need

for treatment at a particular point in time. As an
example, an insurer or similar entity may require a
provider to document the “medical necessity” for
treatment in the patient’s record. Treatment programs
or clinics are routinely visited by utilization-review staff
who review treatment records, including progress notes,
for documentation of medical necessity.
 Documenting Treatment Necessity

■ Billing/payment documentation: In the event of a

dispute over the amount or type of services
rendered, progress notes substantiate the fact that
professional mental health services were rendered
on a given date and that the therapist’s billing was
consistent with the nature of services rendered.
 Documenting Treatment Necessity
■ Standards of third parties
Psychotherapists regularly enter into agreements with
third parties such as insurance companies or managed
care organizations. A therapist who elects to contract with
such entities should be aware of the organization’s
specific practice guidelines and/or treatment standards.
In contrast to the general legal and ethical standards
cited earlier, these guidelines and standards often
contain specific requirements for documentation of
mental health services, including progress note entries.
Practice guidelines and like documents are often
 Evidence Based Practice for Progress
Notes
■ Collaborative relationship.
– All evidence-based interventions in mental health and
addiction treatment are based on a collaborative
relationship between an individual with an identified
need (e.g., help overcoming a substance use disorder,
depression, or related issues, such as assistance
finding a job) and a direct service provider (e.g.,
addiction counselor, recovery coach, case manager, or
job coach) or team of providers. This principle implies
that the two individuals work together to solve
problems, achieve goals, and overcome barriers to
Evidence Based Practice for Progress
Notes
■ Person centered planning.
– A related principle to the collaborative
relationship is a focus on person-centered
planning. Person-centered planning implies that
the consumer/client is given control over his or
her treatment and that all treatment
interventions are selected to help this individual
achieve self-defined goals. This principle also
implies that direct service providers are
Evidence Based Practice for Progress
Notes
■ Goal directed services.
– All evidence-based interventions are designed to
achieve specific outcomes or treatment goals.
Evidence-based interventions are usually
manualized, highly structured, and based on a
set of guidelines. Even if an intervention is not
designated as an evidence-based intervention,
such as case management or peer-driven
services, it is still being used to accomplish a
Evidence Based Practice for Progress
Notes
■ Measurable and reasonable goals.
– This principle indicates that the goals-outcomes
(short- & long-term) selected by consumers and
direct service providers need to be observable,
measurable, within the individual’s capacity (i.e.,
reasonable), & logically connected to the
intervention being implied. This principle also
implies that direct service providers and
consumers need to avoid selecting
Air Travel Video
4 Types of Contacts

■ Engagement & treatment planning.

– This is usually the first activity that occurs between a
direct service provider and consumer/client (crisis
contacts occasionally occur before this activity). This
activity occurs before any treatment intervention has
been established or delivered and can reoccur over time
(at least the treatment plan development part).
Treatment plan development can include monitoring
behaviors to establish a baseline rate for a particular
target behavior. Engagement is an individualized
process, but it is not an unlimited activity. If direct
4 Types of Contacts

■ Service delivery.
– After a working relationship has been developed
and a treatment plan has been established, the
next logical series of service contacts are
activities associated with a particular treatment
intervention. Frequency, intensity, and duration of
contacts are based on consumer preference and
the particular intervention that is being used.
 4 Types of Contacts
■ Crisis-based interactions.
– Crisis-based contacts are, by default, unplanned or unpredicted contacts outside the
established treatment plan. In addition, to meet the criteria of “crisis”, the individual will
require assistance that cannot be delayed or diverted. Many direct service providers
erroneously label predicted or expected behaviors as a crisis. Most crisis events are
actually predictable events that were not addressed in the treatment planning process.
For example, a relapse of alcohol or other drugs for an individual who recently
completed addiction treatment is not unexpected. In addition, if a behavior occurs
frequently (more than two or three times), it is, by default, not a crisis, but rather a
predictable behavior that requires an intervention. Most of these mislabeled events will
probably fall under the first activity of treatment plan development (e.g., need to revise
plan to address ongoing behavior) or service delivery (e.g., relapse prevention or
planned assertive outreach due to a relapse).
4 Types of Contacts

■ Closure or transition.
– All effective or evidence-based interventions have a
beginning and an end-point. Closure activities are used
to praise individuals for completing a particularly
treatment intervention as well as achieving a planned
goal, and helping them to either move on to the next
goal or close services. If the intervention does not have
an end-point, it cannot be evaluated. If an intervention
cannot be evaluated, it’s probably ineffective or, worse,
detrimental to the client/consumer. Transitioning
activities can also be used to end an intervention that
Progress Notes

■ Application of the 3 Ws (who, where, & when)

■ All progress notes begin with a list of individuals involved in the activity, where the
activity occurred, and when (include the total amount of time involved in the
activity).
 Elements of Documentation of a
Treatment Session
■ Depending on the evolving circumstances of each case, certain purposes of
documentation will be more crucial than others at various points in treatment. For
instance, if a patient's mental status deteriorates and he or she becomes
threatening, the purpose of carefully documenting the practitioner's professional
response and clinical decision-making and the purpose of risk
management/malpractice protection will predominate.

■ In a case where a patient who has significant medical, family and mental health
problems is being served by several different practitioners, documentation dealing
with coordination of the professional efforts of the various practitioners will
predominate.
 Elements of Documentation of a
Treatment Session
■ A proper progress note, which need not be particularly extensive, in most cases
merely several sentences, should include:
– 1) the date and length of the contact;
– 2) the specific services provided, including CPT [Current Procedural
Terminology] descriptions and codes; in the case of other non-clinical services
(i.e., case management, advocacy, referral, etc.) indicate the service(s) in
words;
– 3) description of the type of contact (i.e.; in person, telephone, mail);
– 4) indication of who initiated the contact (i.e.; regularly scheduled session,
patient showed up without appointment, phone call by patient, phone call by
patient's family who put patient on the phone, inquiry from another
practitioner/service provider who is with the patient in the emergency room
and puts the patient on the phone);
 Elements of Documentation of a
Treatment Session
■ 5) statement of where the contact took place (i.e.; office, if a home visit - the
address visited, if by phone - the phone number called);
■ 6) indication of who, besides the patient, was involved in the contact (i.e.; patient,
family, other practitioner, friend);
■ 7) a description of the themes of the session, in generic terms, addressing
particular symptoms, feelings, thinking, beliefs or behaviors (i.e., pain, anxiety,
dysphoria, suspiciousness, avoidance, etc.) or relating to specific relationships or
situations (i.e.; work problems, interpersonal relationships, parent-child problems,
marital relationship, school problems, the effects of chronic physical illness);
■ 8) an assessment of the patient’s mental status during the session, relating this to
the patient’s baseline mental status and the patient’s mental status in the recent
past;
 Elements of Documentation of a
Treatment Session
■ 9) notation of any symptoms or complaints that may indicate a physical health
problem (i.e., side effects of psychotropic medication, sleep problems, confusion);
■ 10) description of any new significant history obtained;
■ 11) description of relevant problems newly identified;
■ 12) description of relevant significant new events (i.e., changes in medication,
results of tests, exacerbation of a concurrent physical ailment, break-up of a
relationship, beginning new relationship);
■ 13) description of therapeutic interventions with clinical justification and reasoning
to support these in relation to the treatment plan and clinical circumstances,
particularly when in response to crisis situations or special/markedly changed
circumstances;
 Elements of Documentation of a
Treatment Session
■ 14) statement of what was accomplished in the session;
■ 15) statement of what wasn't accomplished in the session that needs to be followed up
on;
■ 16) details of obstacles to progress in treatment, if any, and a plan to address these; and
■ 17) a description of a plan for further care or follow-up (including date and time of next
appointment), changes in diagnosis and/or treatment plan/goals, if any, and reasoning
to support these changes (particularly when in response to crisis situations or
special/markedly changed circumstances) and any referrals made or testing ordered
(including the nature of the referral, to whom the referral is made, the reason for the
referral, tests ordered and the reason they were ordered, and the patient’s response to
the referral and/or ordering of tests).
 Documenting Progress of Treatment

■ Evaluating the outcome of the activity requires minimal effort and writing when
delivering a well developed treatment intervention. On the other hand, a poorly
developed treatment intervention will lead to an increase in effort, time, and writing
in order to evaluate an activity. It is difficult to evaluate an activity if it is unclear why
the activity was delivered. In other words, if you are lost in the woods, it is difficult to
know if you are making progress toward finding a way out.
 Documenting Progress of Tx

■ Evaluating an activity requires only a few, clear statements about the expected goal. These
statements include:
– A brief note about the expected goal (e.g., the goal today was to improve the skill of saying no
to alcohol by role playing and modeling assertiveness skills for saying no to family members )
– A brief note about the outcome (e.g., After several role plays [we both switched the roles],
Carol was able to comfortably say no to multiple requests for drinking without stuttering or
becoming passive)
– A brief note about the next step (e.g., Carol is going home this weekend and has agreed to
write down any situations where she will be asked to have a drink and what she does about
the request. Carol also has a backup plan of calling her sponsor if she struggles to say no to
a family member)
– A brief note about the next appointment (e.g., we decided to meet next Monday to review
how Carol used the skill of saying no and if it helped her avoid drinking over the weekend).
 Documenting Progress of Tx

■ Another example: •
– A brief note about the expected goal (e.g., John selected the goal of submitting
two job applications by today without my help) •
– A brief note about the outcome (e.g., John submitted one job application, but
his car broke down before he could drop off the second one at the department
store) •
– A brief note about the next step (e.g., John wants to complete the step, so he is
going to have his brother help him fix his car by next week. If he can’t fix the
car by Friday, he will call me and I will give him a ride to the department store
to drop off the job application) •
– A brief note about the next appointment (e.g., we decided to meet next
Tuesday, if John doesn’t call me this Friday, to practice interviewing for when he
gets a chance to talk to an employer).
 Elements of Documentation of a
Treatment Session

■ A good progress note is clear, brief, and linked to the treatment plan. In essence, the
progress note tells a simple and easy to follow story about a treatment intervention
and an individual’s response to the intervention over time.
■ Progress notes are used to report only on the outcome of the intervention and are
not used as a diary of conversations or a verbatim recording of each session
 Common Errors in Progress Notes

■ Recording dialogue between clinician and client (e.g., the client said ……. and then I
said……. and the client responded by saying…….). Dialogue is rarely necessary to
record and will lead to wasted time writing an extended note. Conversations are
expected to occur with the intervention, but the details of the conversation are
usually not necessary to record. It is okay and often useful to summarize important
information noted by clients/consumers in the session, but only when the
information is relevant (and new) to the established treatment plan (e.g., the client
noted that her ex-boyfriend is getting out of prison next week and that he is a “big”
trigger for her using cocaine).
 Common Errors in Progress Notes

■ Recording detailed reports of what occurred in the session (e.g., on the first role
play, Carol was unable to ……… so I tried it again, this time I said …………, after that
try Carol then tried to…………). Details are not needed, particularly if the outcome
was achieved, as planned. If the intervention or activity did not produce the desired
result, simply report that it didn’t work and try something else. The progress note is
not used to record that the clinician understands how to implement the activity; that
is the job of a supervisor.
 Common Errors in Progress Notes

■ Recording excessive or extraneous details associated with the planned activity or

reasons for why the activity did not occur or was not completed (e.g., John explained
to me that he thinks the fuel pump in his car needs to be repaired or that ………, he
told me that he called his brother about the problem and his brother said……..).
Excessive or extraneous details of behaviors are not necessary when they are not
directly related to the intervention or planned activity. Simply note that John’s car is
broken and that he has a plan to get it fixed (or not). Summary statements are
easier to follow and comprehend and should be used to organize detailed
information in the progress note.
 Common Errors in Progress Notes

■ Recording details about repetitive behaviors (e.g., Julie called me again this week
telling me about the argument she had with her father, Julie explained that her
father ……….., which led to Julie wanting to hurt herself, again, by …………………). Even
if the behavior is the target of an intervention, such as learning how to be assertive,
reducing the need to self-mutilate, reducing drinking, learning how to manage anger
or avoid negative people, it is not necessary to provide extensive detail about the
behavior, particularly if the behavior has been explained at least once in the form of
a functional analysis.
 Common Errors in Progress Notes

■ Writing an extensive note that correlates with the amount of time spent with clients.
Some direct service providers feel compelled to write long notes if they spend an
extensive amount of time with clients during an activity. Teaching someone how to
shop for healthy and affordable food, accompanying a client to an AA meeting,
looking for an affordable apartment, or learning how to ride a bus while managing
panic attacks can take hours to complete (and multiple opportunities to practice the
skills), but the progress note needs only to state that these skills-training services
were delivered and the consumer’s response to the training/intervention (e.g.,
apartment or job acquired, increase time in the store while having a panic attack
and not running out of the store, client understands bus schedule will try it on his
own tomorrow, needs more training, or not effective at behavior change). A four-
hour, evidence-based activity and a 15-minute conversation will require about the
same amount of words and space on a sheet of paper (or field in a computer).
 Common Errors in Progress Notes

■ Using vague or ambiguous terms to describe target behaviors, goals, or interventions. Commonly
used and abused words in progress notes include:
– Motivation: avoid the term, except when referring to Motivational Interviewing. Instead of
using the word motivation, which often implies that the person is choosing not to be
motivated (i.e., lazy), describe the destination that a person will reach (e.g., entering
treatment) or the activity that they will perform (e.g., walk around the block twice this week).
– Quality of life: be specific instead of using this term. What aspect of quality of life (e.g.,
housing, safety, relationships, health, or leisure activities) will the person address?
– Self-esteem: this is a ambiguous term that cannot be observed and is rarely related to
anything but self-esteem scales. Again, what aspect of self-esteem is being addressed; e.g.,
body image, depression, self-destructive thoughts, the impact of stigma, or relationship
issues? There are multiple effective cognitive-behavioral and behavioral techniques that can
be used to address negative thoughts and behaviors, but only if the specific thought or
behavior is identified. Self-esteem is colloquial and over-used term within Western culture.
 Common Errors in Progress Notes

■ Happy or happiness: Happiness cannot be measured and, even if this

emotional/psychological state could be reliably measured, it is a fairly unstable emotion
or thought. Instead, focus on what will make the individual happy and in their words? You
cannot reliably measure increased or decreased happiness, but you can reliably
measure activities, such as time with children (or significant others), access to social
events, participation in leisure activities, or learning a new hobby that will impact
happiness (if the consumer selects these activities).
■ Compliant (e.g., Medication compliant): this is an outdated medical-model term that
should not be used when developing a person-centered plan. Compliance does not exist
in a collaborative relationship. Do you ask your husband/ boyfriend or wife/ girlfriend to
be more compliant with your demands in the relationship? Even physicians understand
that they can’t order their patients to be more compliant, but they can work with them to
improve adherence to the medication regimen.
 Common Errors in Progress Notes

■ Satisfaction: another commonly abused term that is usually used to describe a

consumers’ evaluation of the clinician’s activity. Surprisingly, most consumers are
satisfied with most activities, even if the treatment is not helpful or needed. The purpose
of working with clients/consumers is to help them achieve treatment goals, not to be
satisfied with the clinician. If clients are achieving their self-defined goals, they will likely
be satisfied; nonetheless, satisfaction should not be used as a proxy measure for
treatment effectiveness or for the appropriateness of treatment.
■ Independence (or empowerment): There are multiple effective interventions designed to
improve individuals’ independence in the community, such as supported employment,
education, and housing. Nonetheless, all these interventions lead to specific outcomes,
such as obtaining a competitive job, completing a degree, or living in an apartment for a
specific amount of time (and reducing rates of institutionalization). Instead of using the
words independence or empowerment, select the specific activity that will promote these
two broad terms
 Common Errors in Progress Notes

■ Addiction or addictive behaviors (or substance use/abuse behaviors): These terms

can be used in a treatment plan, but even within the treatment plan, the objectives
will need to specify the behavior being addressed as well as the target drug (i.e., the
drug of choice). Avoid using broad terms, such as substance use behaviors or
addictions (or mental illness), and describe the specific behavior that was
addressed in the activity, such as saying no to a drug dealer, discussing the pros &
cons of entering treatment, finding leisure activities that don’t require alcohol,
identifying triggers, listing negative thoughts that lead to drug use, or engaging
supportive family members in the treatment process.
Examples of Information that
Therapists May Want to Include in
Progress Notes
•Treatment modality used
•Progress, and/or lack of progress
•Treatment plan
•Modification(s) of the treatment plan
•Clinical impressions regarding diagnosis, and or symptoms
•Relevant psychosocial information
•Safety issues; danger to self/others
Examples of Information that
Therapists May Want to Include in
Progress Notes
•Clinical emergencies/actions taken
•Medications used by the patient
•Treatment compliance/lack of compliance
•Clinical consultations
•Collaboration with other professionals
•Therapist’s recommendations
•Referrals made/reasons for making referrals
Examples of Information that
Therapists May Want to Include in
Progress Notes
•Termination/issues that are relevant to the termination process
•Issues related to consent and/or informed consent for treatment
•Information concerning child abuse, and/or elder or dependent adult abuse
•Information reflecting the therapist’s exercise of clinical judgment.
Impression & Plan

– Should be NEW and UPDATED every day •

– Most important part of the note •
– Not necessary to include all stable problems •
– Identify your plans •
– Be specific •
– Avoid “to consider” •
■ Use if/then statements instead •
– Each problem should have a separate plan
Impression & Plan

■ Use your plan to communicate what you need to

know •
■ What questions do you need your consultants to
answer? •
■ What are you troubled by? •
■ Should be a working document!
Do’s & Don’ts of Progress Notes

■ Be concise. Document all necessary information but avoid extraneous details, such
as in this example:
■ “Patient moved to Kansas at age 4. Her parents separated when she was 6 and
they moved back to Chicago, then reunited and moved to Indiana, where father took
a job as a shoe salesman. When he lost that job, they moved back to Chicago and
divorced for good. Mother remarried a fireman, who was an alcoholic; they stayed
together for 2 years until …”
■ Instead, simply write:
■ “Patient’s childhood was chaotic with many moves; her mother remarried x 3. No
physical or sexual abuse …”
Do’s & Don’ts of Progress Notes

■ Include adequate details. Do not exclude information critical to explaining treatment

decisions. Describe the symptoms the patient is reporting and the signs you see—or do
not see.
■ This example offers insufficient detail:
■ “Patient’s parents told her that they just bought a new car. She recalled the first car they
had gotten when she was little, and how that made her happy. She talked about the first
car she owned. Plan: Add lithium …”
■ By contrast, the following example explicitly describes signs and symptoms. Also be sure
to include a short explanation when changing, discontinuing, or adding a medication:
■ “Patient reports her mood is much improved. She cannot recall what made her feel so
depressed last week. She is hyperverbal, talking rapidly, gesticulating as she talks—
much more animated, as compared to psychomotor-retarded presentation of last week,
when SSRI was started. Assess: Bipolar switch. Plan: Add lithium, 300 mg bid, and
titrate.”
Do’s & Don’ts of Progress Notes

■ Be careful when describing treatment of a patient

who is suicidal at presentation. Your notes must
contain clear, well-reasoned explanations for:
– discontinuing suicide precautions
– not hospitalizing outpatients who express suicidal
ideation
– and record the patient’s exact response.
Do’s & Don’ts of Progress Notes

■ If the patient attempts or commits suicide shortly after the visit, your progress note may be your
best—and only—defense against a malpractice claim. This example offers no convincing argument
that the patient will not attempt suicide:
■ “Patient reports that he feels better. He denies suicidal ideation. He thinks the antidepressant is
working. Nursing notes indicate no problems. He would like to get dressed and take a walk outside
…”
■ Instead, verbatim patient statements offer more-concrete proof that the patient wants to live:
■ “He said he is his family’s sole support and could never abandon them …”
■ “He said it would kill his mother if he took his own life …”
■ “She said suicide is against her religion …”
■ Simply writing “No evidence of suicidal/homicidal ideation” raises the question of whether you
asked the patient if he or she has considered suicide or just looked for a sign indicating suicidality.
Always ask
Do’s & Don’ts of Progress Notes

■ Remember that other clinicians will view the chart to make decisions about your
patient’s care. Consider this example:
■ “Patient just moved to this area and requests amitriptyline and chlorpromazine. The
risks of combining these medications were explained to him, but he insisted, so will
order.”
■ If another provider is to grant the patient’s request, more details are needed:
■ “Patient states that he has been on every antipsychotic and antidepressant on the
market—including the newest drugs—over 20 years. He says nothing works for him
except this combination. The potential anticholinergic and other severe adverse effects
associated with this combination were explained to him, and his responses indicated
that he clearly understands the risks. He states, ‘These are the only drugs that have kept
me from hearing voices and being depressed and suicidal. I want to stay on this
combination.’ ”
Do’s & Don’ts of Progress Notes

■ Write legibly. Historically many doctors are encouraged to write illegible notes as a
defense against legal action. The reasoning: the defendant can testify to anything
since no one can read the notes anyway.
■ Illegible notes annoy and frustrate the people who cannot read them and inspire a
lack of trust and confidence in the doctor who wrote them. And they are not likely to
fool a jury.
Do’s & Don’ts of Progress Notes

■ Respect patient privacy. Do not name or quote anyone who is not essential to the
record. Identifying another patient by name or Social Security number—even the last
4 digits—is a breach of privacy. For example:
■ “Charlene claimed R2803 followed her into the rest room and raped her…”
■ Did patient R2803 actually do this? What if Charlene’s psychosis prompted her to
make delusional claims about other patients and staff? If her case ends up in court,
patient R2803 is named in connection with an unproven allegation. Naming R2803
in Charlene’s chart identifies him as a psychiatric patient at that facility, thus
violating his privacy.
 CLINICAL DOCUMENTATION &
RECORDKEEPING IN GROUP / FAMILY /
CONJOINT THERAPY
■ Even when a patient is being seen in group, family or conjoint therapy, the patient
must have his or her own patient record. The practice of writing one note for each
group, family or conjoint session and then placing a copy of that note in the chart of
each patient who participated in the session is not appropriate, even if each patient
is referred to only by his or her initials in the one note. Additionally, notes of group,
family or conjoint therapy that are placed in a patient’s record should be kept
separate from, and written on a separate page than any notes relating to individual
therapy sessions. In this manner, if a patient’s clinical record must be disclosed, this
can be accomplished easily without disclosing information about other persons with
whom he or she is receiving group, family or conjoint therapy.
 CLINICAL DOCUMENTATION &
RECORDKEEPING IN GROUP / FAMILY /
CONJOINT THERAPY
■ For documentation of a group, family or conjoint therapy session, a note which
reflects the information that should be documented in a general progress note as
indicated above should be written and should be supplemented by addition of
comments about the patient’s functioning in the group/family/couple session and
his or her reactions and responses in the context of the group/family/couple
process. The progress/session note for each person in the group, conjoint or family
therapy, should focus on that individual’s mental status, behavior, participation and
functioning in the session, and their reactions and responses to the themes and
processes that arose during the session. It should avoid, to the extent possible,
mentioning any identifiable material from or about other particular members of the
group, couple or family, unless this is necessary for clarity. In writing an individual
group therapy note for each group member, only the name of the individual group
member whose note is being written should appear in that note.
 CLINICAL DOCUMENTATION &
RECORDKEEPING IN GROUP / FAMILY /
■
CONJOINT THERAPY
In the case of group therapy the number of patients attending the group session should
be documented in the progress/session note, along with the initials of the other patients
who attended. A separate attendance list of the patients in each group, by session (date
of service) should be filed in a group therapy record folder so that there is a record of
which patients attended which group and when.
■ In the case of family and conjoint treatment, the very nature of the treatment involves
specific identifiable persons. Thus, to protect the privacy of those persons as much as
possible in case a patient’s record must be revealed at some point, the persons, other
than the patient in whose chart the progress/session note is being placed, should be
referred to without using their names. The note written for each patient in the family or
couple should focus on the family/couple dynamics as they impact on that individual
patient. Before such a family/conjoint therapy record is disclosed, the practitioner should
obtain a HIPAA compliant informed consent from each person age 12 or over who is
identified as a patient, even if only by their position in the family/relationship, before
disclosing the family/conjoint therapy record kept for the patient in question.
Progress Notes

■ Therapists occasionally utilize progress notes to refresh their recollection of clinical

information from prior therapy sessions. This review may be particularly helpful
when an extended period of time has elapsed since the last patient contact. Also, in
some treatment settings, such as community clinics that are staffed by interns, a
patient may receive services from different therapists during one continuous
treatment episode. In such an instance, progress notes provide a source of clinical
information that informs a therapist about the efficacy of clinical interventions that
may have been utilized earlier in the patient’s treatment.
Discharge Summaries
 Elements of an Appropriate Interval or
Closing/Termination Summary
■ An interval or closing/termination summary, which may be abbreviated or elongated
depending on the circumstances of a particular case, documents the practitioner’s
thoughtful reflection on the clinical course of the patient’s treatment (to date in
relation to an interval summary, or with regard to the entire period of treatment in
relation to a closing/termination summary). Such summaries can be useful if the
patient later seeks treatment from another practitioner and requests that a
summary be sent to that practitioner. The documentation of a proper interval or
closing/termination summary, includes:
 Elements of an Appropriate Interval or
Closing/Termination Summary
■ 1) The dates the patient was referred, first contacted the practitioner and was first
seen, the referral source, and the time period covered by the summary (if this is a
closing/termination summary, the date the patient was last seen and the last
contact with the patient);
■ 2) A synopsis of the initial reason for and background circumstance of the referral,
the presenting problem(s) from the patient’s perspective at intake, the patient’s
initial clinical presentation, and the initial assessment, including the initial
diagnoses and initial identified problems as identified by the practitioner;
 Elements of an Appropriate Interval or
Closing/Termination Summary
■ 3) A review of the problem areas and symptoms addressed in treatment, the treatment
modalities used, of the patient’s clinical course in treatment during the treatment period
in question (noting changes, if any, in the patient’s symptoms, thinking, emotions,
beliefs, behaviors and other areas of biopsychosocial functioning), and of the extent that
the identified symptoms/problems were resolved and the treatment goals established
were achieved during the treatment period in question; a brief assessment of the
patient’s condition at the end of the time period in question; and, if this is an interval
summary, a notation explaining any changes in diagnosis, prognosis, or the
treatment/service plan;
■ 4) A summary of any concurrent treatments, including the provider(s) of such
treatments, the names and dosages of medications prescribed, other treatments
rendered or any other relevant assessments performed; the steps taken to coordinate
care with other practitioners (including the extent and success of achieving
collaboration, or any problems that interfered with collaborative efforts), the results of
any referrals made or testing ordered, and the impact/results of the other concurrent
treatments;
 Elements of an Appropriate Interval or
Closing/Termination Summary
■ 5) A statement regarding the circumstances of the termination of treatment
(precipitants, was it planned or unplanned?, was it mutually agreed upon by patient
and the practitioner?, did the patient stop coming and, if so, what steps were taken
to address this and with what results);
■ 6) Final diagnoses and a statement as to the patient’s functioning, as well a
statement as to which, if any, of the concurrent treatments (including medication)
the patient is receiving the patient intends to continue (if so, from whom and to what
extent) and does not intend to continue (if so, what are the patient’s reasons for
discontinuation of those services);
 Elements of an Appropriate Interval or
Closing/Termination Summary
■ 7) A statement detailing any referrals or recommendations provided to the patient
regarding further care, and the patient’s response to such referrals and
recommendations; and
■ 8) A statement of whether the patient poses a risk of decompensation, suicidality,
assaultiveness, homicidality, relapse back to alcoholism or substance abuse,
inability to care for himself or herself, of being victimized, of victimizing others, or is
at any other serious risk at the time of termination/closing, the basis of the risk
assessment, details of the steps taken to address any of these risks, and the results
of such steps.
“The written word is the greatest
sacred documentation.”
― Lailah Gifty Akita, Pearls of Wisdom: Great mind