7 Report and Record Keeping
Report and Record Keeping Introduction
As we learned in Unit 1, one of the 12 core functions of the addictions counselor is report and record keeping. Report and record keeping includes charting the results of the initial assessment and treatment plan; writing reports, progress notes, and discharge summaries; and documenting any additional client-related data. In this chapter we will be covering information on report and record keeping best practices.
Why keep records?
If you didn’t write it down, it didn’t happen. One reason to keep records is to demonstrate “proof” that a client was provided with services. It helps with justification of billing for these services. When documenting services, it is important to include the client’s name, the date and time services were provided, the duration of the services (e.g., 2 hours for a treatment group), the type of service, details regarding the service (e.g., what was said and/or done), and the signature of the team member making the entry.
Records provide communication. Records can provide information to clients, professionals (including members of the clinical team), and other interested parties. Keeping well-documented records can help with continuity of care, making sure that all involved parties are working collaboratively to provide quality care.
Informed consent. A client’s record should include documentation for informed consent. Informed consent is the process by which a client is provided with the relevant and necessary information regarding treatment recommendations so they may make a well-considered decision as to whether or not they want to participate in treatment. If the client agrees to the treatment recommendation(s), they must sign an informed consent document, which states that the client understands potential risks and benefits of treatment and that they are making the autonomous yet collaborative decision to enter treatment.
Case conceptualization. Good and organized record keeping helps members of the interdisciplinary team with case conceptualization. It provides the information necessary for understanding a client’s presenting issues and needs, which in turn can help with mapping out a plan and treatment interventions.
Client progress. Comprehensive record keeping helps track the client’s progress. Tracking the client’s progress arms the counselor with the knowledge needed to make informed treatment decisions. It presents the needed information to know what is working, what might not be working, and what needs to be changed. Thorough record keeping can help with justifying clinical decisions.
Protection. Sound record-keeping practices protect both the client and the provider. As previously mentioned, record keeping helps with continuity of care and ensuring the client is provided quality care. This protects the client. But what about the counselor? In the case of a lawsuit or other challenge to the counselor’s competence, record keeping can demonstrate proof that the treatment provided was appropriate to the client’s needs and goals.
Tips for Clinical Documentation
- Avoid abbreviations as they can be unclear. Abbreviations that are common usage and would easily be recognized are acceptable (e.g., HIV)
- Entries should be written using objectivity and nonjudgmental language.
- When creating handwritten entries, if a mistake is made draw a single line through the error, add the date and time and initial.
- Handwritten entries need to be legible
- Professional, clinical language should be used. Avoid language that is too informal.
- When documenting information regarding client suicidality or homicidality, make sure to be thorough.
- Complete a risk assessment and document the results
- Describe any actions taken to ensure client safety or the safety of others and why those actions were taken
- If taking specific actions isn’t necessary, explain how and why you reached this conclusion
The Chart
There are various record-keeping documents that are included in a client’s chart. In this section we will cover those that are most commonly found.
Informed Consent
As mentioned previously, the informed consent document is the one in which the client agrees with the treatment to be provided and consents to treatment.
Intake Forms
There are various documents that are completed at the time that a client enters treatment. They include such information as the client’s demographic information, emergency contact information, and method of payment information.
Release of Information
When collateral information is needed and/or there are other parties the counselor will need to maintain contact with regarding the client’s treatment, a release of information must be signed and dated by the client. Without a written release of information, a counselor cannot discuss the client’s involvement with or progress in treatment. A release of information must include what information is to be shared and with whom. It isn’t uncommon that releases of information are signed to allow the counselor to discuss a client’s treatment with individuals such as client’s family members/significant other(s), a client’s primary care physician or psychiatrist, or representatives of the justice system, such as a client’s probation officer.
Assessment
As mentioned in chapter 5, assessment is the process by which the counselor/program gathers a thorough client history and evaluates the client’s strengths, weaknesses, problems, and needs. The assessment, including relevant findings, should be included in the clinical documentation. Often a narrative summary (a detailed summary of the information gathered for the assessment) accompanies the assessment, as does a clinical diagnosis and level of treatment recommendation.
Progress Notes
Progress notes provide information regarding personal communication, such as individual or group counseling sessions, case management services, etc. They will include such information as content of an interaction with the client, interventions used, client progress, etc. Progress notes should include detailed information, but only that which is relevant and necessary.
The most common formats for writing progress notes include DAP (Data, Assessment, Plan) and SOAP (Subjective, Objective, Assessment, Plan).
Treatment Plan
As mentioned in chapter 6, the treatment plan is the roadmap of the treatment process. Treatment plans include problem statements, goals related to problems, and the steps both the client and counselor will take to assist the client in reaching goals.
Continued Stay Review
As outlined in Illinois 2060, there needs to be ongoing assessment of a client’s progress in treatment to determine if the client is appropriate to remain in the current level of care or needs a higher or lower level of care. The continued stay reviews are included in the client’s chart.
Discharge Summary/Discharge Paperwork
When a client is no longer actively receiving treatment in, or no longer requires an ASAM level of care, discharge paperwork needs to be completed and included in the chart. This includes a continuing recovery plan and a discharge summary. The discharge summary needs to include the reason for discharge, the client’s progress relative to the goals on the treatment plan, and a prognostic statement of the client’s condition at the time of discharge.
Confidentiality
The United States Health Insurance Portability and Accountability Act (HIPAA) outlines federal regulatory standards regarding the lawful use and disclosure of protected health information. Maintaining HIPAA compliance ensures that sensitive client information is protected and secured.
Protected Health Information (PHI)
Protected Health Information refers to individually identifiable health information. This information can be in electronic, paper, or oral form. PHI is in essence any information related to an individual’s physical or mental health. PHI includes such items as a client’s:
- Name
- Address
- Social security number
- Date of birth
- Contact information including email address and phone number
- Medical record or account numbers
Although there is a great deal more information regarding client confidentiality and HIPAA compliance, the bottom line is that patient records are confidential and it is imperative that action is taken to ensure client confidentiality. Hard copies of client records need to be kept in locked and secured cabinets in locked offices or storage rooms. Electronic records are to be protected using various technical safeguards, including, but not limited to, encryption tools and firewalls.
Records of HIV-Positive Clients
It is important to note that there are specific state and federal laws that protect confidentiality of HIV-related information. In addiction treatment settings, records regarding a client’s +HIV status need to be kept in a separate medical chart. This information is only to be shared only with members of the medical team unless otherwise disclosed by the client themselves.
references
Bradshaw KM, Donohue B, Wilks C. A Review of Quality Assurance Methods to Assist Professional Record Keeping: Implications for Providers of Interpersonal Violence Treatment. Aggression and Violent Behavior. 2014 May; 19(3): 242-250. doi: 10.1016/j.avb.2014.04.010. PMID: 24976786; PMCID: PMC4066213.
Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016, December 1). How to keep good clinical records. Breathe (Sheffield, England). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297955/