Todd is a freshly minted licensed chemical dependency counselor entering into his first effort as a private practice clinician. Todd is focused on the paperwork end of his job. Todd knows he needs to develop a practical system of tracking the progress of his clients. From the moment they step in the door to the moment they leave, Todd must document every interaction for referral, legal, living, insurance and client use. One of the strongest demands will be for organized progress notes.
Beginning to Make Progress Notes for Substance Abuse Clients
Assuming you are writing progress notes as a counselor, you have certain clinical responsibilities. These demands will change from client to client, however you should have a clear working knowledge of the terminology you will use within your discipline.
Each client comes to you with certain internal needs and certain ties to the external community. You will need to address each of these. Generally, these fall into realms of medical, social, legal and personal. Medically, your progress notes are relied on by physicians, institutions and, perhaps most importantly, insurance markers. Notes must have a dedicated section to your specific knowledge of the client and should contribute information about the client for each interaction with the client. Notes should contain information such as "Client is awake and orientated at 6 a.m. and reports sleeping well with no problems" or "Client had difficulty following questions regarding date, time and place. Client insisted it was Christmas 2005." Both of these add specific information important to someone in the process.
Along with the physician and nursing notes, your notes will be considered in the medical evaluation of your client. Contributing medical diagnosis is most likely beyond your realm, however, reporting supporting information for the medically designated codes are important. Most medical notes will begin with a physician assigning temporary codes including those from the Diagnostic and Statistical Manual (DSM) - IV. You will not be required to know each DSM code, however, you should be ready to access the information the code represents. If the patient has been diagnosed as depressed as well as dependent on a substance, then you should be prepared to contribute something to both areas. For example, "Patient exhibited a flat affect during questions about his fight with his wife" as well as "patient states a continued clean time of 12 days."
Be careful not to overstep the bounds of your license in reporting medical information.
The treatment team for your client might include a social worker. However, the client has social needs. These not only include living arrangements but also food, transportation, child care and a host of other demands. You will need to be aware of the client's needs as well as available social solutions. When you make a note of a social need, make certain to note the responsible agency your will be referring the need to for fulfillment. For example, "Client needs transportation for medical appointment on Thursday, June 14. I have contacted the local transport office which has agreed to provide bus vouchers to be given to the client on June 7." Be careful with dates and make certain they provide accurate information to any agency accessing the record for coordination of care.
In substance abuse counseling, many clients arrive with a host of legal issues. You will be responsible for reporting on these issues as part of your overall progress of the client. If you have been appointed to act as a part of a court-ordered plan, make certain to check with the court for requirements they have for your client. Because there are different courts and causes, the requirements may change for the client based upon their progress through the system. For example, parole requirements are quite different from probation requirements. Make certain you not only write the correct note but take the correct action with the information. The legal system has little tolerance for tardiness and clinicians can have an immense effect on the legal system. Treat the client's notes as if they were your own. Your actions or inaction will have legal consequences that linger far into the future.