● Client reactions to interventions ● Reactions of others ● Significant events
A medical analogy can illustrate the importance of such attentive 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 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-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. Information from Others Documenting information received from collateral contacts varies according to the purpose of the information and the manner and setting in which it is received. Likewise, child custody evaluations and investigations of domestic violence
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. 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. P – Continue to meet with Samantha weekly to prepare for the upcoming reunification, fortify stress management, social, and parenting skills. How did Darlene navigate the various confidentiality concerns in this progress note? Confidentiality was protected with no identifying information about collaterals disclosed. The language is not harming, discriminatory, or judgmental, with a tone of identifying progress and strengths. Wiger (2022) outlines common problems with progress notes, including vagueness, irrelevant information, and inability to elicit essential information from uncooperative clients, all of which can lead to ethical issues. In addition, taking shortcuts in documentation, such as not charting a separate note for each member attending a group or family therapy session, can be problematic. A simple framework for objectively assessing clinical notes is that another reader should be able to answer the following questions (Martha St. Enterprises, Inc., 2009): ● What brought the client to seek help? ● What was done about that presenting problem? ● What were the interventions and results? ● What was the disposition?
rely on third-party information (Henry, 2018). Documenting third-party information is a significant aspect of clinical record keeping in these situations.
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