Documentation Basics
This type of note records a patient’s current status and ongoing treatment.
What is a progress note?
This document outlines goals and strategies for treatment.
What is a treatment plan?
This approach emphasizes motivation and readiness to change.
What is motivational interviewing?
This must be signed before treatment begins.
What is consent for treatment?
This best practice includes documenting client quotes when relevant to support clinical observations.
What is using direct client statements?
This federal law protects the privacy of patient health information.
What is HIPAA?
This summarizes a patient’s condition when leaving treatment.
What is a discharge summary?
These should be specific, measurable, and time-limited.
What are objectives?
This protects professionals from legal claims.
What is liability insurance?
This documentation format stands for Subjective, Objective, Assessment, and Plan.
What is SOAP?
This regulation specifically protects substance use treatment records.
What is 42 CFR Part 2?
This includes measurable steps toward achieving treatment goals.
What are objectives?
These are the counselor’s actions to help the client meet objectives.
What are interventions?
This occurs when a provider fails to meet the standard of care.
What is negligence?
This format includes Data, Assessment, and Plan.
What is DAP?
This term refers to the obligation of an individual or organization to safeguard entrusted information.
What is confidentiality?
This document is completed at the beginning of treatment to gather history and needs.
What is an intake assessment?
This ensures the plan reflects the client’s needs, strengths, and input.
What is individualized treatment planning?
Confidentiality can be broken if a client poses this type of threat.
What is a danger to self or others?
The ASAM Criteria are primarily used for this purpose in treatment settings.
What is determining level of care?
This is required when correcting an error in a record.
What is drawing a single line through the error and initialing it?
This record is a legal document used to request client information from another provider.
What is a release of information form?
This should be sought when a counselor is unsure how to proceed with a case.
What is supervision?
This document may require a clinician to release client records by court order.
What is a subpoena?
This key rule means that services not written in the record are assumed not to have occurred.
What is “if it isn’t documented, it didn’t happen”?