Service Documentation & Records-Notes

Service Documentation & Records-Notes

*Please note, Office staff do not have access to any notes, including the contact log 

Client Office Contact Form: (“Client Details” folder) Used for any scheduling, billing or general office information.  Please do not put any clinical communication in this form.

Contact log: (“Client Notes” folder) Any clinical communication (phone, text, email) between counselor and client, parents, insurance, other providers, etc. must be documented in this log on Theranest to ensure proper documentation and follow up.

*Please note that e-mail is for scheduling, billing and exchanging documentation only.  There shall be no clinical discussion via e-mail.

Progress notes: After each session, counselors are required to complete a progress note for each session with bulleted notes including Session details, Diagnosis, Mental Status, Risk Assessment, Session Focus, Therapeutic Intervention and Planned Intervention. If counselors are supervised, these notes will need supervisor approval and should be completed within 24 hours of the appointment. Personal information including medical diagnosis(s) and names should not be included in these notes as they may be sent to the client’s insurance carrier to authorize or approve services.

Session notes: Session notes are considered counselor personal notes and are required in case needed by Executive staff in cases of emergency and crises for anecdotal information.

Treatment plan: This should be completed by the 3rd session, containing agreed upon goals between the client and counselor.  The counselor will review and update this plan every 10 sessions (or sooner if necessary) to include changes in goals and completion dates of achieved goals by setting a timer every 3 months for weekly clients and every month for bi-weekly or monthly clients.  Once a goal has been completed, counselors are to put interventions utilized. If supervised, Clinical Supervisor will need to approve plan once created.*

*Treatment plans can have a maximum of 10 goals.  If a client has not completed parts of their plan, but more goals are to be added, the Clinical Supervisor must sign off on the previous plan to close it out.  Once closed, the counselor can create a new plan, making sure to incorporate the incomplete goals from the previous plan as well as new ones.

Monitoring progress: The Treatment plan and progress notes should be used to guide the treatment process per each individual. Counselor (and Supervisor if LAC) will determine session structure, interventions and activities per each individual client. If supervised, Supervisor will monitor client progress parallel to counselor closely throughout client’s treatment.

Termination: If the client cancels 2 consecutive sessions with no return contact to counselor or office by end of appointment week:

  • Any clients who only attend 1 intake session do not need a termination form and can be archived by the Counselor
  • Counselor will complete termination form for client and alert Clinical Supervisor to close the case
    • If client terminates naturally, the same procedure is to be followed post the final session
  • Clinical Supervisor will close the case according to termination closure and will archive the client
    • If the client decides to return at a later date:
      • For maintenance-Clinical Supervisor will open the previously closed case
      • For new treatment-if more than 6 months from last session, the Clinical Supervisor will open a new case for the client

Example breakdown of session structure post intake: