A well-documented assessment, however, presumes that the documenter has interviewing skills that will elicit the important information needed for good documentation (Leon & Pepe, 2013). Yet it also depends on the practitioner knowing what and how to document. The biopsychosocial assessment is the foundation of a clinical record. It encompasses multiple areas related to the client’s Progress Notes Progress notes are written documentation detailing every session. Despite the fact that progress notes are susceptible to error, good progress notes protect practitioners against future litigation regarding misdiagnosis or treatment. What constitutes a good progress note? A good progress note not only proves that an encounter took place but also details the type and effect of treatment so that any reader can ascertain a client’s issues, diagnosis, and progress in therapy. Progress notes should include information about each session’s content or topics, their relevance to treatment plan objectives and goals, and the use of interventions and their outcomes. Progress notes should reflect the current status (based on the therapist’s clinical observation during the session) of a client’s diagnosis, the medical necessity of services, and progress or setbacks in relation to treatment objectives and goals (Wiger, 2022). Kagle and Kopels (2008) recommend that progress notes should include the following information: ● Any new information about the client’s needs ● The provider’s assessment of the client’s status with regard to needs ● The client’s actions or activities related to the service plan ● Services provided by the provider ● Evaluation of progress Any changes needed to meet the goals of the service plan Although these guidelines might seem overwhelming to the hurried practitioner who has too little time between sessions to record their notes, they do provide a goal for documenting. A medical analogy can illustrate the importance of such attentive Case Study 2 Samantha is a client who has been receiving counseling from Darlene, a seasoned practitioner, for the past year. Samantha sought out Darlene’s services at the recommendation of her attorney following the state’s removal of her three children, ages four, six, and nine, due to severe neglect. At the start of treatment, Samantha explains that at the time of her children’s removal she was experiencing severe depression precipitated by the children’s father abandoning them and Samantha’s mother dying within the same month. The children’s removal further exacerbated her depression. Fourteen months later Samantha has stabilized, and reunification with her children has begun. It is expected that the children will return to her full custody in about three months. Samantha is looking forward to the transition, but she is also scared and anxious about being overwhelmed with parenting responsibilities. Samantha meets with Darlene weekly, and Darlene is in regular contact with Samantha’s case worker, attorney, and children’s therapists. Samantha and Darlene have discussed openly the limits of confidentiality in her therapy, and Samantha, at times, chooses to withhold information from Darlene that might reflect negatively in her client record because she knows it will be viewed by other professionals involved in her family’s care. She has been reluctant to share the extent of her anxiety about the upcoming transition; however, Darlene is familiar with these types of reunifications and is able to normalize Samantha’s concerns and introduce salient interventions without Samantha having to feel overexposed. At their most recent session, they discussed Samantha’s relationship with her boyfriend, who has recently lost his job and is at risk of losing his apartment and anticipated possible changes to the relationship as the children return home. In addition, they reviewed self-
history and functioning. Essentially, the assessment unpacks the presenting problem; describes it in context; documents relevant developmental, family, medical, interpersonal, educational, employment, and social history; and identifies client strengths and limitations, including risk and protective factors (Wiger, 2022). record keeping: For a patient receiving a medication, the failure of the practitioner to record the setbacks, limitations, progress, plans, adverse effects, and clinical observations might cause the treatment to be futile or, worse, dangerous. The chances of the practitioner being accused of negligence would be high. To satisfy managed care insurers, progress notes are “expected to provide information about the client, the implementation of the intervention, and goal progress or attainment” (Kane et al., 2002, p. 204). Notations are best if they are documenting observable or measurable behavior. Acceptable progress notes include five elements (Kane et al., 2002): ● The contact
● The client’s behavior and/or affect ● Client reactions to interventions
● Reactions of others ● Significant events
Ethical dilemmas in documentation arise in a managed care environment when protecting client confidentiality conflicts with disclosing sufficient information to satisfy managed care requirements. Progress notes are often organized in one of two recognized formats: SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan). Another format serves to help train novice workers: STIPS (Symptoms, Topics of discussion, Interventions, Progress and plans, Special issues). These structured/semi-standardized formats assist providers in focusing documentation. soothing and relaxation techniques for Samantha to use during times of increased anxiety, problem-solved parenting dilemmas, and discussed some of Samantha’s friendships. The following is an example of the progress note for this session using the SOAP format. S – Client reports looking forward to her children returning home and says that her boyfriend and friends are excited for her. She reports that her weekend visit with the children went very well, although she is worried that her nine-year-old has been getting into a lot of trouble in the foster placement. O – The reunification efforts have included increasing Samantha’s unsupervised time with all three children at once. A primary social support of Samantha’s is experiencing stressors that have impacted the relationship. Samantha neither confirmed nor denied that she is experiencing increased stress. Samantha is concerned about her oldest daughter. A – This time of reunification typically includes an increase in parental stress. While Samantha did not endorse feeling an increase in stress based on previous discussions, I suspect this is because she does not want to do or say anything that will jeopardize the reunification. As the experience of increased stress was normalized, Samantha wanted to revisit previous stress management skills. She continues to show determination in demonstrating behaviors that would lead to reunification. She thoughtfully engaged in a discussion about analyzing various social supports and their usefulness to her during this important time. The session ended with Samantha asking for help in problem-solving her concerns about her daughter.
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