2.4 Documentation
Whatever career path you choose (therapist, school counselor, probation officer, CYS worker, case manager, social worker, etc.), you are required to document your interactions with those you serve and professionals you consult with regarding a specific client. There is an old saying, “If you didn’t document it, it “never happened!!” No matter what job or career path you choose, every position you will hold requires strong written communication skills, whether it’s an email, a written report, case notes, or some type of interoffice memo. Your ability to communicate clearly and concisely while being grammatically correct is important in order for all who read your documents to understand your message.
Depending on the job you have, you will be required to document in the style that is required. So let’s start with this premise: Document all contact!! If you try to call a client or student, document the date, time, type of activity, and the out come.
Examples
- 1/17/2021 @ 10:15 AM T/C to Kim Smith. No answer, will attempt followup (remember to always sign your documentation/note including your credentials) Jo Jankoski, ED.D., LCSW, MS, CCTP
- 1/20/2021 @ 12:15 PM, T/C from Karen Desk, teacher from Penn State High School, regarding Paula Puppy. Informed me that she received the Conner Forms and will complete them immediately and will return. Jo Jankoski, ED.D., LCSW, MS, CCTP
These are just a few examples of the importance of documentation.
So what type of documentation is kept? In the clinical setting:
Biopsychosocial history, clinical assessment and clinical diagnoses, treatment plans, which would include long and short term goals, interventions used, outcomes and the release of information with informed consent of the client are only good for 120 days. The client can rescind the consent at any time.
Remember all contacts with 3rd parties must be documented!! This includes parents, family members, coaches, teachers, other providers, etc.
Any critical incident (suicide attempt, child abuse allegations, domestic violence, threats against others, threats against you the professional must be documented.
Description of all contacts with clients, including the type of contact (for example, in person or via telephone or in individual, family, couples, or group counseling), and dates and times of the contacts must be documented.
Your documentation (Case Notes) must be:
- Clear, concise, precise, timely, accurate, and complete
- Your Case notes should describe the behaviors reported by the client or collateral informant
- Record comments/statements made by the client or the collateral informant
- Record YOUR observations
- Substantiate ALL conclusions and or judgements
When writing case notes or any type of documentation, please avoid using diagnoses, clichés, street talk, jargon, stereotypes, and prejudices.
The question is how do we document our clinical diagnosis? The American Psychiatric Association (APA) in the newest version of the