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 Diagnostic and Statistical Manual of Mental Disorders 5 Edition, doesn’t provide much guidance. As Human Service Professionals, we need to consider both the PURPOSE of our communication and the AUDIENCE for that communication. We must be mindful of the potential misuse of our documents by others, which will influence the way we present our findings. No two agencies will be alike when recording clinical diagnoses. Some agencies may be using electronic records while other smaller agencies may use client charts. What we do know regarding recording diagnoses and codes from the DSM-5 are the following:
The principal diagnosis must be listed first with a recommended statement such as “principal diagnosis” or “reason for visit” should be added afterwords.
If there are multiple diagnoses present, list them in a descending hierarchy regarding clinical importance.
Include and use all relevant subtypes and specifiers.
Please note that this version of the DSM-5 includes the ICD #10 Codes (International Statistical Classification of Diseases and Related Health Problems); these codes were adopted on October 1, 2014. NOTE Z codes can NOT be the presenting problem.
The following are the steps to use in writing your clinical diagnosis
- Identify the diagnosis that meets the criteria
- Write the name of the disorder (e.g., Disruptive Mood Dysregulation Disorder)
- Add any subtypes or specifiers that met the clients presentation
- Add the diagnostic code (you can add the code either before the criteria or with the specifiers. Remember you must include both the DSM-5 & the ICD Code. One in bold and the other code in parentheses (ICD-10), for example, 296.99 (F34.8) NOTE: DSM-5 presents diagnostic specifiers in lowercase rather than capitalized letters. It is recommended to ensure that the readers recognize that all words that are part of the diagnostic description be capitalized!!
EXAMPLES of DSM-5 Clinical Diagnosis:
- Jo meets the following criteria for (F34.1) 300.4 Persistent Depressive Disorder, mild severity, with early onset, with pure dysthymic syndrome, Z 91.410 Personal history (past) of spouse/partner violence
- Pat meets the following criteria for the following diagnoses: 309.21 (F93.0) Separation Anxiety Disorder (Principal Diagnosis), 300.3 (F42) Hoarding Disorder
Activity
Watch and complete the interactive Quiz
Overview: The interactive video quiz follows a contact visit vignette. Crystal Smith has been living in a group home following physical abuse at home. In the video, a social worker conducts an ongoing interview with Crystal, located at the group home. She pauses throughout the video to provide the learner with opportunities to practice editing case note examples to be more concise. The learner is also asked to watch a brief segment of the video and record a case note detailing the segment in a concise manner. The total video run time is approximately 2 minutes and automated feedback is provided for all self-assessment questions.