Documentation Review Addiction Counselor Exam

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The client record is the most important tool to ensure continuity of care
Documentation contributes to service delivery by:
Reducing replication of services
Presenting a cohesive longitudinal record of clinically meaningful information
Ensuring reimbursement for services
Assists in guarding against malpractice
What was done
By whom
Were they adequately credentialed
Records professional services
Intake
Differential diagnosis
Placement criteria used in decision making
Treatment and other services provided
Response to treatment interventions
Referral services and outcome
Clinical course
Reassessment and treatment plan reviews
Records compliance with state, accreditation and payor requirements
Ease transition to other programs and to referral resources
Prevent duplication of information gathering when possible

Facilitates Quality Assurance
Documenting the appropriateness, clinical necessity and effectiveness of treatment
Substantiating the need for further assessment and testing
Support termination or transfer of services
Identifying problems with service delivery by providing data to support corrective actions
Adding to methods to improve and assure quality of care
Providing information that is used in policy development, program planning and research
Providing data for use in planning professional development activities.
Fosters communication and collaboration between multidisciplinary team members
Administrative Documentation
Accurate, concise reports including recommendations, referrals, case consultations, legal reports, family sessions and discharge summaries
Conducted at admission and at specified intervals through out care
Types
Client identifying and demographic information
Referral source name and address
Financial information
Signed client rights
Informed consent for treatment
Releases of information
Orientation to program
Outcome measures
Client placement information
Clinical Documentation
Screening
Assessment
Treatment Plan
Progress Notes
Discharge Summary
Treatment Plan
Plots out a roadmap for the treatment process
Treatment plans are completed once
A diagnosis is made
Level of care is determined
Client is admitted to the program
Level of care is determined based on
Diagnosis
Client’s strengths and assets
At minimum, the plan is a flexible document that uses a stage-match process to address:
Identified Substance Use Disorders (SUDs)
Recovery support environment
Potential mental health conditions
Potential medical issues
Employment
Discharge planning begins at admission
Discharge planning begins at admission and continues throughout treatment
Summarize
Services delivered
Accomplishment of goals and objectives
Discharge recommendations (referrals, continuing care etc)

Education
Spirituality
Social needs
Legal needs
Disposition of records by discontinued programs

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