Group documentation

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Grand Canyon University *

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PCN-162

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Health Science

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May 31, 2024

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docx

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Uploaded by MajorWolverine4418

Maria Bode PCN-162 October 18, 2020 Sheila Harris Documentation Requirements Participants who are attending group therapies have the right to a complete and effective experience. There are documentation requirements that are put into place to ensure an individualized experience for each client. Their files should include consent for treatment, a release of information, and treatment plans that include goals, clinical notes, and a discharge plan. When a client signs consent for treatment, they do not necessarily state that they understand the complete treatment process. They merely declare that they agree and are willing to be treated (Henden, E. (2013). When a client is under the influence of mind-altering substances or in denial of addiction, it can be challenging for the clinician to explain them. A clinician that is working with a client that is not in the state of mind to make sound decisions, the focus is to have them agree to treatment that aides them in their recovery process and explain to the client they can leave or stop treatment at any time can be beneficial in the beginning. Clients must sign a release of information before any information can be shared with anyone. ROI's must also be signed before identifying information can be documented in an integrated health database. These releases must be specific to the individual that the information is being released to and the type of information that can be disclosed. HIPPA laws protect a client. Therefore, there cannot be any information released without the consent of the client. This 1

release of information includes family members, probation officers, other doctors outside of the facility, or any other persons requesting information. A treatment plan created for a client will include benchmarks that need to be met to give a client complete wrap around services. These include an on-site medical evaluation, referrals to primary care, assessment of needs of services, and transportation if needed (Druss, B. (2006). Among these services, there are goals that should be set in place that are attainable to the client. When a client can obtain small goals, the big picture of treatment is less likely to overwhelm them. These goals differ between each client and are based on their level of needs. Clinical notes are a vital part of the client's success. Clients benefit from accurate case notes in their files. Accurate case notes will include a subjective outline of what the client states, what other clinicians have documented and sometimes what other family members have stated that is pertinent to the client, how the client feels; their plans, goals, and their acceptance of help being provided, The objective of the case notes is to document in a factual manner on which the counselor observes and any written documentation from an outside facility. Within the objective, the client's demeanor, general appearance, and affect should be noted. The client's assessment will summarize and analyze the subjective and objective portions of the client's case notes. These notes include any clinical diagnosis and labels of the client's behavior observed by the counselor (Cameron, S (2002). The discharge portion of a client's file would include any action plans for further treatment, treatment, and the prognosis; including any interventions used, progress within their treatment, and what the client gained in treatment (Cameron, S (2003). The discharge plan should be shared with the client in the beginning as well close to the end of the treatment to 2

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