Section 2 Practice Dimensions

PD 7 Documentation


The recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client-related data.

Competency 108

Demonstrate knowledge of accepted principles of client record management.


  • Regulations pertaining to client records.
  • The essential components of client records, including release forms, assess- ments, treatment plans, progress notes, and discharge summaries and plans.


  • Composing timely, clear, complete, and concise records that comply with regulations.
  • Documenting information in an objective manner.
  • Writing legibly.
  • Using new technologies in the production of client records.


  • Appreciation of the importance of accurate documentation.


Uses of The Competencies

During a 1999 survey of inpatient and outpatient programs at Georgia’s largest State psychiatric facility, Georgia Regional Hospital in Atlanta, The Competencies was used to develop standards for determining the competency of counselors, psychologists, and clinical supervisors working in substance abuse treatment services. The Competencies also was used to develop a policy proce- dure and test instrument for the facility by the Joint Commission on Accreditation of Healthcare Organizations.


Competency 109

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.


  • Federal, State, and program confidentiality rules and regulations.
  • The application of confidentiality rules and regulations.
  • Confidentiality rules and regulations regarding infectious diseases.
  • The legal nature of records.


  • Applying Federal, State, and agency regulations regarding client confidentiality.
  • Requesting, preparing, and completing release of information when appropriate.
  • Protecting and communicating clients’ rights.
  • Explaining regulations to clients and third parties.
  • Applying infectious disease regulations as they relate to addictions treatment.
  • Providing security for clinical records.


  • Willingness to seek and accept supervision regarding confidentiality rules and regulations.
  • Respect for clients’ rights to privacy and confidentiality.
  • Commitment to professionalism.
  • Recognition of the absolute necessity of safeguarding records.

Competency 110

Prepare accurate and concise screening, intake, and assessment reports.


  • Essential elements of screening, intake, and assessment reports, including but not limited to:
    • psychoactive substance use and abuse history
    • physical health
    • psychological information
    • social information
    • history of criminality
    • spiritual information
    • recreational information
    • nutritional information
    • educational or vocational information
    • sexual information
    • legal


  • Analyzing, synthesizing, and summarizing information.
  • Keeping a concise and relevant record of information.
  • Organizing information in a presentable format for ease of access and review.
  • Documenting referral information.
  • Documenting source of referral information.


  • Willingness to develop accurate reports.
  • Recognition of the importance of accurate records.

Competency 111

Record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.


  • Current Federal, State, local, and program regulations.
  • Regulations regarding informed consent.


  • Keeping timely, clear, complete, and concise records that comply with regulations.


  • Recognition of the importance of recording treatment and continuing care plans.
  • Willingness to incorporate professional assessment in records.

Competency 112

Record progress of client in relation to treatment goals and objectives.


  • Appropriate clinical terminology used to describe client’s response to intervention and progress made toward completing treatment goals and objectives.
  • How to review and update records.


  • Preparing clear and legible documents.
  • Documenting changes in the treatment plan, client status, client response to and outcome of interventions, level of care provided, and discharge status.
  • Using appropriate clinical terminology and standardized abbreviations.
  • Noting client’s strengths and limitations in achieving treatment goals.
  • Recording client’s response to and outcome of interventions.
  • Recording changes in client’s status, behavior, and level of functioning.
  • Noting limitations of treatment provided to client.


  • Recognition of the value of objectively recording progress.
  • Recognition that timely recording is critical to accurate documentation

Competency 113

Prepare accurate and concise discharge summaries.


  • The components of a discharge summary, including but not limited to:
    • client profile and demographics
    • presenting symptoms
    • diagnoses
    • selected interventions
    • critical incidents
    • progress toward treatment goals
    • outcome
    • continuing care plan
    • prognosis


  • Summarizing information.
  • Preparing concise discharge summaries.
  • Completing records in a timely manner.
  • Reporting measurable results.


  • Recognition that treatment is not a static, singular event.
  • Recognition that recovery is ongoing.
  • Recognition that timely recording is critical to accurate documentation.

Competency 114

Document treatment outcome, using accepted methods and instruments.


  • Accepted measures of treatment outcome.
  • Current research related to defining treatment outcomes.
  • Methods of gathering outcome data.
  • Principles of using outcome data for program evaluation.
  • Distinctions between process and outcome evaluation.


  • Gathering and recording outcome data.
  • Incorporating outcome measures during the treatment process.


  • Recognition that treatment and evaluation should occur simultaneously.
  • Appreciation of the importance of using data to improve clinical practice.



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