Professional Practices: Referral & Documentation

Professional Practices:Referral & Documentation Melody Kipp, PhD, LMHC Life & Work Soulutions, Inc.

Referral & Documentation • Florida Certification Board, 2004 • The process of facilitating the client’s utilization of available support systems and community resources to meet needs identified in clinical evaluation and/or treatment planning.

Referral & Documentation • The Referral Purpose: • The purpose of the referral is to Establish and Maintain relationships with: • Civic groups • Agencies • Other professionals • Governmental entities • The community-at-large

Referral & Documentation • The Referral Purpose: • Identify service gaps • Expand community resources • Help to address unmet needs

Referral & Documentation • The Referral Process: • Continuously assess and evaluate referral resources to determine their appropriateness. • Differentiate between situations in which it is most appropriate for the client to self-refer to a resource and instances requiring counselor referral.

Referral & Documentation • The Referral Process: • Arrange referrals to other professionals, agencies, community programs, or other appropriate resources to meet client needs. • Explain in clear and specific language the necessity for and process of referral to increase the likelihood of client understanding and follow through.

Referral & Documentation • The Referral Process: • Exchange relevant information with the agency or professional to whomthe referral is being made in a manner consistent with confidentiality regulations and generally accepted professional standards of care.

Referral & Documentation • The Referral Process: • Evaluate the outcome of the referral.

Referral & Documentation • Documentation is the recording of the: • Screening and intake process • Assessment • Treatment plan • Clinical reports • Clinical progress notes • Discharge summaries • Other client-related data

Referral & Documentation • The 2004 Florida Statutes: • 491.0148 Records.--Each psychotherapist who provides services as defined in this chapter shall maintain records. The board may adopt rules defining the minimum requirements for records and reports, including content, length of time records shall be maintained, and transfer of either the records or a report of such records to a subsequent treating practitioner or other individual with written consent of the client or clients.

Referral & Documentation • The American Counseling Association • www.counseling.org • Counselors maintain records necessary for rendering professional services to their clients and as required by laws, regulations, or agency or institution procedures.

Referral & Documentation • Confidentiality of Records. • Counselors are responsible for securing the safety and confidentiality of any counseling records they create, maintain, transfer, or destroy whether the records are written, taped, computerized, or stored in any other medium.

Referral & Documentation • Permission to Record or Observe. • Counselors obtain permission from clients prior to electronically recording or observing sessions.

Referral & Documentation • Client Access. • Counselors recognize that counseling records are kept for the benefit of clients, and therefore provide access to records and copies of records when requested by competent clients, unless the records contain information that may be misleading and detrimental to the client. In situations involving multiple clients, access to records is limited to those parts of records that do not include confidential information related to another client.

Referral & Documentation • Disclosure or Transfer. • Counselors obtain written permission from clients to disclose or transfer records to legitimate third parties unless exceptions to confidentiality exist as listed in Section B.1. Steps are taken to ensure that receivers of counseling records are sensitive to their confidential nature.

Referral & Documentation • The American Psychological Association • www.apa.org • Psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to:

Referral & Documentation • Facilitate provision of services later by them or by other professionals, • Allow for replication of research design and analyses, • Meet institutional requirements, • Ensure accuracy of billing and payments, and • Ensure compliance with law.

Referral & Documentation • The counselor’s responsibilities for documentation include: • Demonstrate knowledge of accepted principles of client record management. • Protect client rights to privacy and confidentiality in the preparation and handling of records, especially in relation to the communication of client information with third parties.

Referral & Documentation • The Documentation Process: • Prepare accurate and concise screening, intake, and assessment reports. • Record treatment and continuing care plans that are consistent with agencystandards and comply with applicable administrative rules.

Referral & Documentation • The Documentation Process: • Record progress of client in relation to treatment goals and objectives. • Prepare accurate and concise discharge summaries. • Document treatment outcome, using accepted methods and instruments.

Referral & Documentation • The Progress Note: • SOAP Notes • The SOAP note format is common to the medical setting and is used by many health care professionals.

Referral & Documentation • The acronym SOAP defines four sections: • (S) for subjective, • (O) for objective, • (A) for assessment, and • (P) for plan.

Referral & Documentation • SOAP Notes: • Subjective (S). The subjective section should include information given or statements made by the patient or the patient family in relation to the current deficits or ability to participate in evaluation or treatment sessions. • Objective (O): Information included in the objective section pertains to exam results, performance on therapy task, and observations made by the clinician.

Referral & Documentation • Assessment (A): This section of the SOAP note contains the problem list and the clinician’s summary of the session, including the patient’s performance and short-term and long-term goals. The clinician generally makes comments on progress in this section. If there are other variable that influence the session, those may be noted in this section as well, such as a suggestion that the patient appears to be a good rehab candidate.

Referral & Documentation • Plan (P): this section contains recommendations and treatment approaches. Treatment plan information may include type of therapy, frequency of therapy, need for further assessment, and plans for discharge

Referral & Documentation • The acronym DAP defines three sections: • (D) for subjective and for objective data • (A) for assessment or intervention • (P) for patient response and plan

Referral & Documentation • "D" - Subjective and objective data about the client: • Subjective - what client can say or feel • Objective - observable, behavioral by therapist • Description of both the content and process of the session

Referral & Documentation • "A" - Intervention, assessment - what's going on? • Working hypotheses, gut hunches • "Depression appears improved this week" • "more resistant ... less involved... "

Referral & Documentation • "P" - Response or revision • What you're going to do about it • Next session date-"couple will call in four weeks" • Any topics to be covered in next session(s), and home work given

Referral & Documentation • The Discharge Summary: • Discharge planning begins at admission. • Discharge summary is the document that tells the patient story from the beginning to the end of treatment, and it details with the patient is going to do in aftercare.

Referral & Documentation • The Discharge Summary includes: • Initial assessment • Diagnosis • Course of treatment • Final diagnosis • Aftercare plan

Referral & Documentation • Saying goodbye to your client is inevitable. • You will most likely have mixed feelings when he or she leaves treatment.

Professional Practices: Referral & Documentation