VII. DOCUMENTATION

The recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client-related data.

 

1. Demonstrate knowledge of accepted principles of client record management.

Knowledge

1. Regulations pertaining to client records.
2. The essential components of client records, including release forms, assessments, treatment plans, progress notes, and discharge summaries and plans.

Skills

1. Composing timely, clear, and concise records that comply with regulations.
2. Documenting information in an objective manner.
3. Writing legibly.
4. Utilizing new technologies in the production of client records.

Attitudes

1. Appreciation of the importance of accurate documentation.

 

2. Protect client rights to privacy and confidentiality in the preparation and handling of records, especially in relation to the communication of client information with third parties. 

Knowledge

1. Program, State, and Federal confidentiality regulations.
2. The application of confidentiality regulations.
3. Confidentiality regulations regarding infectious diseases.
4. The legal nature of records.

Skills

1. Applying Federal, State, and agency regulations regarding client confidentiality.
2. Requesting, preparing, and completing release of information when appropriate.
3. Protecting and communicating client rights.
4. Explaining regulations to clients and third parties.
5. Applying infectious disease regulations as they relate to addictions treatment.
6. Providing security for clinical records.

Attitudes

1. Willingness to seek and accept supervision regarding confidentiality regulations.
2. Respect for the client's right to privacy and confidentiality.
3. Commitment to professionalism.
4. Recognition of the absolute necessity of safeguarding records.

 

3. Prepare accurate and concise screening, intake, and assessment reports. 

Knowledge

1. Essential elements of screening, intake, and assessment reports, including, but not limited to: -psychoactive substance use and abuse history, -physical health, -psychological information, -social information, -history of criminality, -spiritual information, -recreational information, -nutritional information, -educational and/or vocational information, -sexual information, -legal information.

Skills

1. Analyzing, synthesizing, and summarizing information.
2. Recording information that is concise and relevant.

Attitudes

1. Willingness to develop accurate reports.
2. Recognition of the importance of accurate records.

 

4. Record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules. 

Knowledge

1. Current Federal, State, local, and program regulations.
2. Regulations regarding informed consent.

Skills

1. Documenting timely, clear, and concise records that comply with regulations.

Attitudes

1. Recognition of the importance of recording treatment and continuing care plans.

 

5. Record progress of client in relation to treatment goals and objectives. 

Knowledge

1. Appropriate clinical terminology used to describe client progress.
2. How to review and update records.

Skills

1. Preparing clear and legible documents.
2. Documenting changes in the treatment plan.
3. Using appropriate clinical terminology.

Attitudes

1. Recognition of the value of objectively recording progress.
2. Recognition that timely recording is critical to accurate documentation.

 

6. Prepare accurate and concise discharge summaries. 

Knowledge

1. The components of a discharge summary, including but not limited to: - client profile and demographics, - presenting symptoms, - diagnoses, - selected interventions, - critical incidents, - progress toward treatment goals, - outcome, - aftercare plan, - prognosis, - recommendations.

Skills

1. Summarizing information.
2. Preparing concise discharge summaries.
3. Completing timely records.
4. Reporting measurable results.

Attitudes

1. Recognition that treatment is not a static, singular event.
2. Recognition that recovery is ongoing.
3. Recognition that timely recording is critical to accurate documentation.

 

7. Document treatment outcome, using accepted methods and instruments. 

Knowledge

1. Accepted measures of treatment outcome.
2. Current research related to defining treatment outcomes.
3. Methods of gathering outcome data.
4. Principles of using outcome data for program evaluation.
5. Distinctions between process and outcome evaluation.

Skills

1. Gathering and recording outcome data.
2. Incorporating outcome measures during the treatment process.

Attitudes

1. Recognition that treatment and evaluation should occur simultaneously.
2. Appreciation of the importance of using data to improve clinical practice.

 

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Email: no@nattc.org | Revised March 1998