Documentation Review
Dr. Dawn-Elise Snipes PhD, LPC-MHSP
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Documenting the Treatment Process
~ The client record is the most important tool to ensure continuity of care
~ Documentation contributes to service delivery by:
~ Reducing replication of services
~ Presenting a cohesive longitudinal record of clinically meaningful information
~ Ensuring reimbursement for services
~ Assists in guarding against malpractice
~ What was done
~ By whom
~ Were they adequately credentialed

Purposes of Clinical Documentation
~ Records professional services
~ Intake
~ Differential diagnosis
~ Placement criteria used in decision making
~ Treatment and other services provided
~ Response to treatment interventions
~ Referral services and outcome
~ Clinical course
~ Reassessment and treatment plan reviews
~ Records compliance with state, accreditation and payor requirements
~ Ease transition to other programs and to referral resources
~ Prevent duplication of information gathering when possible
Purposes of Clinical Documentation
~ Facilitates Quality Assurance
~ Documenting the appropriateness, clinical necessity and effectiveness of treatment
~ Substantiating the need for further assessment and testing
~ Support termination or transfer of services
~ Identifying problems with service delivery by providing data to support corrective actions
~ Adding to methods to improve and assure quality of care
~ Providing information that is used in policy development, program planning and research
~ Providing data for use in planning professional development activities.
~ Fosters communication and collaboration between multidisciplinary team members
Documentation: CFR 42 part 2
~ Confidentiality of Alcohol and Drug Abuse Patient Records
~ 42 CFR Part 2 applies to all records relating to the identity, diagnosis, prognosis, or treatment of any patient in a substance abuse program in the US
~ Prohibition, data that would identify a patient as suffering from a SUD or undergoing SUD treatment
~ 42 CFR Part 2 allows for disclosure
~ where the state mandates child-abuse-and neglect reporting
~ when cause of death is being reported
~ with the existence of a valid court order
Documentation – Release of Information
~ A written consent form requires ten elements (42 C.F.R. § 2.31(a); 45 C.F.R. § 164.508(c)):
~ 1. the names of the programs making the disclosure
~ 2. the name of the individual or organization that will receive the disclosure
~ 3. the name of the patient who is the subject of the disclosure
~ 4. the specific purpose or need for the disclosure
~ 5. a description of how much and what kind of information will be disclosed
~ 6. a patient’s right to revoke the consent in writing and the exceptions
~ 7. the program’s ability to condition treatment, payment, enrollment, or eligibility of benefits on the patient agreeing to sign the consent
~ 8. the date or condition when the consent expires if not previously revoked
~ 9. the signature of the patient (and/or other authorized person)
~ 10. the date on which the consent is assigned
~ When used in the criminal-justice setting, expiration of the consent may be conditioned upon the completion of, or termination from, a program

Documentation – Information Sharing
~ Information can be shared within an agency on a need to know basis with person on the treatment team
~ Information sharing can be done
~ With a release
~ To the client
~ Under specific circumstances
~ Agencies generally have policies for who is allowed to release information
~ Clients have the right to review and amend their records
~ If request to view or amend the record is denied, a written explanation must be provided to the client

~ Protects insurance coverage of workers when they change or lose their job
~ Safeguards the privacy of information
~ Combats waste in healthcare delivery
~ Simplifies administration of health insurance
HIPAA Records and Record Storage
~ Medical records are legal documents
~ All states have policies regarding record retention
~ Medical records of adults are retained for 7 years
~ Medical records of minors may be retained for longer
~ Agencies and solo practitioners should have policies identifying retention and storage policies
~ CFR 42 2.19, 2.16
~ All records must remove patient identifying information
~ Sanitize software, printer ribbons, fax hard-drives, printer hard drives
HIPAA Records and Record Storage
~ All client records and identifying information must be kept out of sight of unauthorized personnel
~ Lists/rosters
~ Attendance records
~ Appointment schedules
~ Computerized information
~ Client records
~ Phone messages
Disposition of records by discontinued programs
~ If a program discontinues operations or is taken over or acquired by another program, it must remove patient identifying information from its records or destroy its records, including sanitizing any associated hard copy or electronic media, to render the patient identifying information non-retrievable in a manner consistent with the policies and procedures established under § 2.16, unless:
~ The patient who is the subject of the records gives written consent to a transfer of the records to the acquiring program or to any other program designated in the consent (the manner of obtaining this consent must minimize the likelihood of a disclosure of patient identifying information to a third party); or
~ There is a legal requirement that the records be kept for a period specified by law which does not expire until after the discontinuation or acquisition of the part 2 program.
Disposition of records by discontinued programs
~ Records, which are paper, must be sealed in envelopes or other containers labeled as follows: “ Records of [insert name of program] required to be maintained under [insert citation to statute, regulation, court order or other legal authority requiring that records be kept] until a date not later than [insert appropriate date]”
~ All hard copy media from which the paper records were produced, such as printer and facsimile ribbons, drums, etc., must be sanitized to render the data non-retrievable
Disposition of records by discontinued programs
~ Records, which are electronic, must be:
~ (i) Transferred to a portable electronic device with implemented encryption to encrypt the data at rest so that there is a low probability of assigning meaning without the use of a confidential process or key and implemented access controls for the confidential process or key; or
~ (ii) Transferred, along with a backup copy, to separate electronic media, so that both the records and the backup copy have implemented encryption to encrypt the data at rest
~ (iii) Within one year of the discontinuation or acquisition of the program, all electronic media on which the patient records or patient identifying information resided prior to being transferred to the device specified in (i) above or the original and backup electronic media specified in (ii) above, including email and other electronic communications, must be sanitized
Disposition of records by discontinued programs
~ The portable electronic device or the original and backup electronic media must be:
~ (A) Sealed in a container along with any equipment needed to read or access the information, and labeled as follows: “ Records of [insert name of program] required to be maintained under [insert citation to statute, regulation, court order or other legal authority requiring that records be kept] until a date not later than [insert appropriate date];” and
~ (B) Held under the restrictions of the regulations in this part by a responsible person who must store the container in a manner that will protect the information (e.g., climate controlled environment); and

Documentation Regulations
~ Many agencies govern the content, scope and quality of documentation
~ Single State Authority (SSA)
~ State service and licensing rules
~ May include
~ time frames for documentation completion
~ Who needs to sign and credential the documents
~ Accreditation Bodies
~ Address quality from an organizational leadership and client care perspective (methadone, CARF, JCAHO)

Documentation Regulations
~ Many agencies govern the content, scope and quality of documentation
~ Third Party Payors (Level of Care Guidelines)
~ Provider Agencies
Documentation Types
~ Screening
~ Referral source
~ Presenting problems
~ Background biopsychosocial information
~ Emotional/mental status
~ Client strengths and preferences
~ Recommendation for assessment or other referral

Documentation Types
~ Intervention Documentation
~ Client identifying information
~ Source of referral
~ Client placement information
~ Screening information
~ Informed consent for services including any drug testing (signed, dated, credentialed by client and counselor, witnessed)
~ Release of information (with all 10 necessary components (see below)
~ Intervention plan (signed, dated, credentialed by client and counselor, witnessed)
~ Summary of progress
~ Copies of correspondence or reports
~ Transfer or discharge summary
Documentation Types
~ Administrative Documentation
~ Accurate, concise reports including recommendations, referrals, case consultations, legal reports, family sessions and discharge summaries
~ Conducted at admission and at specified intervals through out care
~ Types
~ Client identifying and demographic information
~ Referral source name and address
~ Financial information
~ Signed client rights
~ Informed consent for treatment
~ Releases of information
~ Orientation to program
~ Outcome measures
~ Client placement information

Documentation Types
~ Medical Documentation
~ Medical history
~ Nursing assessment
~ Physical exam
~ Lab tests (often including TB and preadmission physical for residential)
~ Records of medical prescriptions and changes in medications
~ Medication Administration Records (MAR)
~ Nursing notes

Documentation Types
~ Clinical Documentation
~ Screening
~ Assessment
~ Treatment Plan
~ Progress Notes
~ Discharge Summary

Electronic Health Records
~ Health Information Technology (HIT) is the secure management of health information on computerized systems
~ Electronic health records help to
~ Track data over time
~ Track progress of those who leave treatment
~ Monitor quality care within the practice
~ Behavioral Health lags in adoption because
~ Cost
~ Technical limitations
~ Lack of standardization of data elements
~ Lack of interoperability of systems
~ Attitudinal constraints
~ Organizational lack of expertise in HIT management
Elements of Clinical Documentation
~ Ethically must be clear, concise, accurate, written in ink, time stamped and dated
~ Documentation is an ongoing responsibility for all professionals and should be completed as soon as possible after the contact
~ Documentation ensures accountability
~ The responsibility for accurately representing the client’s situation rests with the counselor and the clinical record, not the client
~ Good clinical documentation spares the client from repeating painful details
~ Language must be objective, but descriptive
~ Documentation must identify persons, places, direct quotations and sources of information
~ Clinical documentation is a legal record and the clinician’s signature indicates the truthfulness of it

Treatment Plan
~ Is a contract between the client, counselor and treatment team, each being responsible for its development and implementation
~ The clinician should recognize that
~ Treatment occurs in different settings over time
~ Much of the recovery process occurs outside of or immediately following treatment
~ Treatment is often divided into phases
~ Engagement
~ Stabilization
~ Primary treatment
~ Continuing care

Treatment Planning
~ Plots out a roadmap for the treatment process
~ Treatment plans are completed once
~ A diagnosis is made
~ Level of care is determined
~ Client is admitted to the program
~ Level of care is determined based on
~ Diagnosis
~ Client’s strengths and assets

Treatment Planning
~ Treatment plans address all biopsychosocial needs
~ Establish what changes are expected through achievable goals
~ Clarifies what interventions and counseling methods will be used to help the patient achieve those goals
~ Sets the measures that will be used to gauge success
~ Incorporates the clients strengths, needs, abilities and preferences
~ Referrals are made to other agencies as needed
~ When referrals are made, collaboration is essential to keep clients from falling through the cracks
Treatment Planning and Confidentiality
~ Information, even within the agency, is restricted to need-to-know.
~ Treatment plans may have to be co-signed by a clinician who is already certified or licensed.
Treatment Planning: Function
~ Action-oriented process that lays out a logical, goal-directed strategy for making positive changes
~ Establishes collaboration between client and counselor so they can prioritize mutually agreeable goals.
Treatment Planning: Structure
~ Achievable goals are selected by assessing and prioritizing clients needs, taking into account
~ Level of impairment
~ Motivation
~ Real-world influences on needs
~ Treatment plans consider client
~ Needs
~ Readiness
~ Preferences and prior treatment history (what did and didn’t work)
~ Personal goals
~ Obstacles
Treatment Planning: Structure
~ Defines
~ SMART Goals
~ Objectives
~ Anticipated type, duration and frequency of services
~ Who is responsible for what
~ Time table
~ Incorporates client input and participation in development
~ Have client prioritize presenting issues
~ Get input on goals and objectives
~ Both counselor and client sign the plan
~ The clinician may also facilitate and manage referrals (i.e. housing, legal, medical)
Treatment Planning: Issues
~ At minimum, the plan is a flexible document that uses a stage-match process to address:
~ Identified Substance Use Disorders (SUDs)
~ Recovery support environment
~ Potential mental health conditions
~ Potential medical issues
~ Employment
~ Education
~ Spirituality
~ Social needs
~ Legal needs
Elements of an Initial Treatment Plan
~ Done at admission (or within 24 hours)
~ Based on information from assessment and screening
~ Serves as the initial roadmap
~ Includes
~ Presenting problems
~ Preliminary goals
~ Type, frequency and duration of service
~ Signature and date of client and counselor w/credentials
Elements of an Individualized Treatment Plan
~ Problem and problem description “Why are you here”
~ Strengths
~ Concrete, measurable goals
~ Objectives
~ Strategies w/ frequency and duration
~ Diagnosis
~ Signature of the client and counselor
~ Signature of clinical supervisor if required
Treatment Planning: Ongoing and Review
~ Ongoing assessment and collaboration is used to regularly review the treatment plan and make necessary modifications
~ Review should be completed at minimum at major or key points in the clients treatment course
~ Admission or readmission
~ Transfer
~ Discharge
~ Major change in condition
~ After 12 months
Progress Notes
~ Document
~ The client’s progress in relation to the treatment plan goals and objectives
~ Problem name and number
~ What client says and does
~ Counselor observations and assessments
~ Continued plans to address the problem
~ New information
~ Format
~ S/O: Specific/objective
~ A/P: Assessment (counselor interpretations)/Plan for how to proceed

Progress Notes
~ Document
~ The client’s progress in relation to the treatment plan goals and objectives
~ Problem name and number
~ What client says and does
~ Counselor observations and assessments
~ Continued plans to address the problem
~ New information
~ Format
~ S/O: Specific/objective
~ A/P: Assessment (counselor interpretations)/Plan for how to proceed

Progress Notes
~ Based on
~ What client says and does
~ What the clinician observes (attitude, demeanor, nonverbals)
~ Counselor’s knowledge and experience
~ Lapse vs. relapse
~ Differential diagnosis
~ Danger to self or others
~ Is not a verbatim transcript, but a cohesive summary

Discharge Summary
~ Discharge planning begins at admission
~ Discharge planning begins at admission and continues throughout treatment
~ Summarize
~ Services delivered
~ Accomplishment of goals and objectives
~ Discharge recommendations (referrals, continuing care etc)

Discharge Summary
~ Elements of the D/C plan
~ Referral source
~ Presenting problems and reason for services
~ Treatment goals, methods and outcomes
~ Outcomes generally pertain to
~ the person’s ability to attain recovery
~ build resilience
~ Work, learn, live and fully participate in the community of choice
~ Condition of client at discharge
~ Prognosis
~ Follow up recommendations (Continuing care/aftercare plan)
~ Counselor signature, date and credentials
Discharge Summary
~ Reasons for discharge
~ Treatment completion
~ Treatment noncompliance
~ Treatment incomplete
Organization of Documentaiton
~ Each page has the client’s name
~ All entries are signed
~ Errors are lined, initialed, dated and “error” written above it
~ Notes should never be removed from a file
~ Late entries and corrections should be noted as such and entered as a separate document
Summary of Clinical Documentation Characteristics
~ Written knowing others will read it
~ Objective
~ Uses descriptive, behavioral terms
~ Avoids jargon/ Keep It Simple
~ Concise
~ Positive