Documentation

A large part of my job is documenting my encounters with clients. There is a set format we have to follow for our notes:

1. Summary of Individual Service Plan (ISP)/Individual Service Treatment (IST)

Discuss goals, objectives ordered and objectives addressed

i.e. If a goal is “search for housing,” I might say that at our meeting today, I helped the client figure out what percentage of his income would be spent on rent each month and linked him to an organization that helps find housing.

2. Provide therapeutic intervention

i.e. Ask client, “How’s the housing search going?”

3. Client response

Quote them, if possible. Include any clinically significant events. Are they compliant with their medications?

4. Justify the need for follow up

Include progress/lack of

5. Plan follow-up

What we’re going to do next session. Include recommendations for modifying the treatment plan.

6. Date of last/next psychiatrist visit

Recovery Resources’ CPSTs write notes concurrently with the appointment. I have my laptop out and will type sometimes while the client is talking but I try not to do it too much to detract from his or her attention. If I don’t have a chance to write notes concurrently, I do it right after the session.

Notes can take up to 15 minutes depending on the content of the session. Sessions are typically between 30 and 60 minutes long. Phone calls are billable (and thus note-worthy) after seven minutes. If someone talks longer than three minutes, they’ll usually talk for seven.