DOCUMENTATION, CASE

PLANNING &
CONTRACTING
October 6, 2014

HOW WAS LAB??

DOCUMENTATION
Why should we keep good records?

Some standard rules

Be as brief as possible and as thorough as possible

KEEP IT OBJECTIVE.
Do not comment on something if it is not of clinical
significance, for example:

Client has an accent (Although English is not the

clients first language, client is fluent. Client turned
down an offer to transfer to a bilingual therapist.)
Clients appearance (Clients appearance is unkempt,
wearing dirty and worn clothing of the wrong size.)
Clients age (Client is a 37 yo female or Cl declines
to answer age, but appears middle-aged and reports
having two grown children.

7 key purposes of
documentation
1.

2.

3.

4.

document diagnosis, treatment and

effectiveness
provides continuity of care
reminder for the provider (you!)
provides subsequent continuity of
care if case is transferred
risk management and malpractice
protection

Continued
5.

6.

7.

compliance with legal, regulatory,

institutional requirements (accreditation,
insurance reimbursements, etc)
quality assurance / utilization review
improve quality of services, provide data for
policy development, program planning, etc.
facilitate coordinated treatment efforts (vs.
fragmented services without knowledge of
what services each member is providing to
client)

Sample formats
Varies by agency/organization
SIRP (situation, intervention, response,
plan)
SOAP (subjective, objective, assessment,
plan)
DAP (data, assessment, plan)

Subjective/situation/data

What was discussed, broadly speaking

How does the client describe the
problem?
Pertinent quotes
Presenting issues
Whether client was on time
How client appeared/sounded to you
(subjectively)

Objective

What did you observe about the client?

(so basically, nothing the client says
goes in this section!)
Usually this space is for: client was
tearful, client displayed flat affect,
clients speech was slurred what you
saw and heard (not words!)

Assessment

Intervention

Response

Plan

Common abbreviations

Logistics to keep in mind

Make sure you have the right case file!

Date and sign every entry
Record your note as late entry if it
doesnt fall chronologically
Initial any crossings-out or changes to to
the case file made after the fact
Put client name/case number on each
page
Dont leave big blank spaces on the
page

Tips and tricks for good

case notes

Use power quotes

Read through existing case notes at the agency to
get a sense of what the note culture is like. This is
not the time to get creative.
Client remains at risk for ____ as evidenced by
____
The current symptoms include
Limited progress in _____
Continues to be depressed/anxious as evidenced
by _____
Client continues to have suicidal ideation as
evidenced by the following comment made during
session: _________

The case file (in real life,

not lab)
LEFT SIDE

Forms (intake)

Billing information

HIPAA forms

Informed consent

Payment receipts

Release of information forms

RIGHT SIDE

Treatment plan

Case notes

Drawings, letters
Case summaries

Who relies on your

documentation?

A note about HIPAA

CASE NOTES AND CLIENT INFORMATION ARE

MEDICAL RECORDS/ PHI (protected health
information).
All patients/clients have the right to access their
medical records at any time.
EXCEPTION: psychotherapy notes.
INCLUDED: medication prescription and monitoring,
counseling session start and stop times, modalities
and frequencies of treatment furnished, results of
clinical tests, and any summary of the following
items: diagnosis, functional status, treatment plan,
symptoms, prognosis, and progress to date.

PLANNING AND
CONTRACTING

Planning and goal-setting

What is the purpose of goal setting with

clients?

Deliberately setting goals is important.

Types of Goals

7 Qualities of well-formed
goals

Contracting

Why a written contract?

Change Worksheet: Motivational

Interviewing