1. Welcome to Unit 8, Documentation! If it isn’t in the client record, it better not have happened.

4. Document all contacts with clients or related to your client. This is done for both legal and administrative reasons. Legally it shows you are providing the service for which you are being paid. Administratively the record is a document of the activities and contacts related to your client. The notes should focus on the client and not on you – brief – not a “process recording”. It is our responsibility to keep the record current.

6. Initial referral Client Demographics (Face Sheet) Initial intake note Psychosocial assessment (with diagnosis) Contact notes (a.k.a. progress notes) Individualized Service Plan (ISP) 90 Day reviews and annual reviews Referrals and releases Previous client records Correspondence to and from others

7. Contact notes written in the chart should always include the following: 1. The focus of the session. 2. Your assessment based on a concise (brief) summary of behavior, appearance, affect. 3. Your intervention – what did you do today to warrant a paid service? 4. The reason for the next contact or the follow-up that will occur.

8. Focus of the Interview Betty came into the office today to discuss her pending discharge from the inpatient unit. The Assessment she seemed anxious about leaving and worried about remaining clean without adequate support, although she left somewhat relieved at the plans in place for her. The Resolution Betty chose an AA meeting site and will attend 90 meetings in 90 days. She was told that she will be referred to out patient group counseling and have a therapist the first 8 weeks after discharge. The Follow-up C.M. will contact Betty next week to see how she is doing with the outpatient support.

10. All contact notes should be dated and labeled. EXAMPLE : 4/16/09 (phone contact with Client) There are a number of other labels you can use, examples? Collateral - contact with someone relevant to the client but not the client. Office visit - client came to the office. Phone - you and the client spoke on the phone. Site visit - you visited the client at the provider agency. Group - you saw the client in a group setting. Home visit - you visited the client in his or her home. Community - you met the client in a community setting.

11. Avoid hostility - do not use your notes to vent hostility about the client Document interactions with the client - document the interaction between you and the client. Document significant aspects of the contact - significant aspects give clues to the client’s state of mind and the problems faced. Document appearance, facial expression and mannerisms, responses to others or to activities, attitudes, and cognitive problems. Be clear and precise - refrain from using general or vague terms. Rather than “Bill was upset today” use “Bill was upset today over the possibility that he may lose his job.

12. Use quotations - The rule is only the exact words spoken by the client go in quotation marks. If you paraphrase do not use quotation marks. Avoid contradictions - your program note must not contradict previous notes without explanation as to what has changed. Use language the client can understand - Avoid jargon used by professionals and write your notes in language the client and the family can understand. Accurately describe disabilities - rather than use terms like afflicted with, cripple, victim, confined to a wheelchair, handicapped, blind, deaf, and dumb, use expressions like a person with…., uses a wheelchair, has partial sight, is hard of hearing or has partial hearing loss, nonverbal.

13. Refrain from using judgmental words to describe the client - some words are more judgmental than others. For example dirty is more judgmental than unclean or nasty is more judgmental than unpleasant. Distinguish between facts and impressions - do not state something as fact that you do not know first hand to be true. Instead use terms like “according to client…” or client seemed….” or “staff felt that client….” Give a balanced view of the client - do not paint the client as entirely positive or negative. Provide evidence that you and the provider are in agreement - Your notes should indicate that you have met with providers, attended planning meetings and worked with providers

14. Use black ink as blue ink does not copy well Never use pencil of correction fluid The notes must be legible The client’s name must be on each page Put the date of the actual contact in the margin Sign every note with the date it was written Notes should indicate what the follow-up with the client will be To correct a mistake 1. Draw a line through the error 2. Write error above the line 3. Write the correction next to the word error 4. Sign or initial and date the line

15. Often plans have to be changed or revised. This can be for a number of reasons, such as the client became ill, the provider closed for snow or overcrowding, the client had a death in the family, the plan is too difficult, the plan is not addressing the real issue, there are new more pressing issues. When the plan needs to be changed: 1. Note the lack of progress toward the goals 2. State why 3. Note the revisions to the plan 4. Revise the actual treatment or service plan

16. I am so angry, my wife and I were just in a family session with our ten-year-old son’s counselor and I told her I lost my temper this week and pushed my son into his bedroom and grabbed him and threw him into his bed. I know I shouldn’t have pushed him, but he was screaming such awful things at my wife, calling her horrible names. (Wife agrees this is what happened, son was out of control, she was glad her husband stepped in) My son’s counselor said; “I’m going to have to call a report into CPS, you can’t throw your son around.” I said fine, go ahead and call, I’m out of this stupid family session, you don’t help us at all you just cause more problems! We’ll be in with our case manager if CPS wants to talk with us! At least she actually helps us.

18. What are some of the things you might do with these upset parents/clients, as their case manager? Think in terms of the specific interventions and skills that you have been studying.

19. So now that we have brainstormed possible interventions, how would you document the “I” in your PIE note for this meeting today? Remember keep it simple and name a specific skill/intervention that you did with this client.

20. Okay, you are almost finished with today’s documentation note. All you need is the “E”. Remember the “E” stands for evaluation and plan. Try typing a sentence or two that documents how today’s meeting ended and what the plan is until the next meeting.

21. Any Questions? Have a wonderful week