Professional Practices: Referral & Documentation

Professional Professional Practices:Practices:Referral & Referral &

DocumentationDocumentation

Melody Kipp, PhD, LMHCMelody Kipp, PhD, LMHC

Life & Work Life & Work SoulSoulutions, utions, Inc.Inc.

Referral & DocumentationReferral & Documentation

Florida Certification Board, 2004Florida Certification Board, 2004 The process of facilitating the The process of facilitating the

client’s utilization of available client’s utilization of available support systems and community support systems and community resources to meet needs identified resources to meet needs identified in clinical evaluation and/or in clinical evaluation and/or treatment planning.treatment planning.


The Referral Purpose:The Referral Purpose: The purpose of the referral is to The purpose of the referral is to

EEstablishstablish and and MaintainMaintain relationships relationships with:with:

Civic groups Civic groups AgenciesAgencies Other professionals Other professionals Governmental entitiesGovernmental entities The community-at-large The community-at-large


The Referral Purpose:The Referral Purpose: Identify service gapsIdentify service gaps Expand community resourcesExpand community resources Help to address unmet needsHelp to address unmet needs


The Referral Process:The Referral Process: Continuously assess and evaluate Continuously assess and evaluate

referral resources to determine their referral resources to determine their appropriateness.appropriateness.

Differentiate between situations in Differentiate between situations in which it is most appropriate for thewhich it is most appropriate for the client to self-refer to a resource and client to self-refer to a resource and instances requiring counselor referral.instances requiring counselor referral.


The Referral Process:The Referral Process: Arrange referrals to other professionals, Arrange referrals to other professionals,

agencies, community programs, agencies, community programs, or or other appropriate resources to meet other appropriate resources to meet client needs.client needs.

Explain in clear and specific language Explain in clear and specific language the necessity for and process of referral the necessity for and process of referral to increase the likelihood of client to increase the likelihood of client understanding and follow understanding and follow through.through.


The Referral Process:The Referral Process: Exchange relevant information with Exchange relevant information with

the agency or professional to whomthe agency or professional to whom the referral is being made in a the referral is being made in a manner consistent with confidentialitymanner consistent with confidentiality regulations and generally accepted regulations and generally accepted professional standards of care.professional standards of care.


The Referral Process:The Referral Process: Evaluate the outcome of the referral.Evaluate the outcome of the referral.


Documentation is tDocumentation is the recording of he recording of the: the: Screening and intake processScreening and intake process Assessment Assessment Treatment plan Treatment plan Clinical reportsClinical reports Clinical progress notesClinical progress notes Discharge summariesDischarge summaries Other client-related dataOther client-related data


The 2004 Florida Statutes:The 2004 Florida Statutes: 491.0148 Records491.0148 Records.--Each psychotherapist who .--Each psychotherapist who

provides services as defined in this chapter provides services as defined in this chapter shall maintain records. The board may adopt shall maintain records. The board may adopt rules defining the minimum requirements for rules defining the minimum requirements for records and reports, including content, length records and reports, including content, length of time records shall be maintained, and of time records shall be maintained, and transfer of either the records or a report of transfer of either the records or a report of such records to a subsequent treating such records to a subsequent treating practitioner or other individual with written practitioner or other individual with written consent of the client or clients.consent of the client or clients.


The American Counseling AssociationThe American Counseling Association www.counseling.orgwww.counseling.org

Counselors maintain records Counselors maintain records necessary for rendering professional necessary for rendering professional services to their clients and as services to their clients and as required by laws, regulations, or required by laws, regulations, or agency or institution procedures. agency or institution procedures.


Confidentiality of Records. Confidentiality of Records. Counselors are responsible for Counselors are responsible for

securing the safety and securing the safety and confidentiality of any counseling confidentiality of any counseling records they create, maintain, records they create, maintain, transfer, or destroy whether the transfer, or destroy whether the records are written, taped, records are written, taped, computerized, or stored in any other computerized, or stored in any other medium. medium.


Permission to Record or Observe.Permission to Record or Observe. Counselors obtain permission from Counselors obtain permission from

clients prior to electronically clients prior to electronically recording or observing sessions.recording or observing sessions.


Client Access. Client Access. Counselors recognize that counseling Counselors recognize that counseling

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


Disclosure or Transfer. Disclosure or Transfer. Counselors obtain written permission Counselors obtain written permission

from clients to disclose or transfer from clients to disclose or transfer records to legitimate third parties records to legitimate third parties unless exceptions to confidentiality unless exceptions to confidentiality exist as listed in Section B.1. Steps exist as listed in Section B.1. Steps are taken to ensure that receivers of are taken to ensure that receivers of counseling records are sensitive to counseling records are sensitive to their confidential nature.their confidential nature.


The American Psychological The American Psychological AssociationAssociation www.apa.orgwww.apa.org

Psychologists create, and to the Psychologists create, and to the extent the records are under their extent the records are under their control, maintain, disseminate, store, control, maintain, disseminate, store, retain, and dispose of records and retain, and dispose of records and data relating to their professional and data relating to their professional and scientific work in order to: scientific work in order to:


Facilitate provision of services later Facilitate provision of services later by them or by other professionals, by them or by other professionals,

Allow for replication of research Allow for replication of research design and analyses, design and analyses,

Meet institutional requirements, Meet institutional requirements, Ensure accuracy of billing and Ensure accuracy of billing and

payments, and payments, and Ensure compliance with law.Ensure compliance with law.


The counselor’s responsibilities for The counselor’s responsibilities for documentation include:documentation include: Demonstrate knowledge of accepted Demonstrate knowledge of accepted

principles of client record principles of client record management.management.

Protect client rights to privacy and Protect client rights to privacy and confidentiality in the preparation and confidentiality in the preparation and handling of records, especially in handling of records, especially in relation to the communication of relation to the communication of client client information with third parties.information with third parties.


The Documentation Process:The Documentation Process: Prepare accurate and concise Prepare accurate and concise

screening, intake, and assessment screening, intake, and assessment reports.reports.

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


The Documentation Process:The Documentation Process: Record progress of client in relation to Record progress of client in relation to

treatment goals and objectives.treatment goals and objectives. Prepare accurate and concise Prepare accurate and concise

discharge summaries.discharge summaries. Document treatment outcome, using Document treatment outcome, using

accepted methods and instruments.accepted methods and instruments.


The Progress Note:The Progress Note: SOAP NotesSOAP Notes The SOAP note format is common The SOAP note format is common

to the medical setting and is used to the medical setting and is used by many health care professionals.by many health care professionals.


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


SOAP Notes:SOAP Notes: Subjective (S).Subjective (S). The subjective section should The subjective section should

include information given or statements include information given or statements made by the patient or the patient family in made by the patient or the patient family in relation to the current deficits or ability to relation to the current deficits or ability to participate in evaluation or treatment participate in evaluation or treatment sessions. sessions.

Objective (O):Objective (O): Information included in the Information included in the objective section pertains to exam results, objective section pertains to exam results, performance on therapy task, and performance on therapy task, and observations made by the clinician.observations made by the clinician.


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


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


The acronym DAP defines three The acronym DAP defines three sections: sections: (D) for subjective and for objective (D) for subjective and for objective

data data (A) for assessment or intervention(A) for assessment or intervention (P) for patient response and plan(P) for patient response and plan


"D" - Subjective and objective data "D" - Subjective and objective data about the client:about the client: Subjective - what client can say or Subjective - what client can say or

feelfeel Objective - observable, behavioral by Objective - observable, behavioral by

therapisttherapist Description of both the content and Description of both the content and

process of the sessionprocess of the session


"A" - Intervention, assessment - "A" - Intervention, assessment - what's going on?what's going on? Working hypotheses, gut hunchesWorking hypotheses, gut hunches "Depression appears improved this "Depression appears improved this

week"week" "more resistant ... less involved... ""more resistant ... less involved... "


"P" - Response or revision"P" - Response or revision What you're going to do about itWhat you're going to do about it Next session date-"couple will call in Next session date-"couple will call in

four weeks"four weeks" Any topics to be covered in next Any topics to be covered in next

session(s), and home work givensession(s), and home work given


The Discharge Summary:The Discharge Summary: Discharge planning begins at Discharge planning begins at

admission.admission. Discharge summary is the document Discharge summary is the document

that tells the patient story from the that tells the patient story from the beginning to the end of treatment, beginning to the end of treatment, and it details with the patient is going and it details with the patient is going to do in aftercare.to do in aftercare.


The Discharge Summary includes:The Discharge Summary includes: Initial assessmentInitial assessment DiagnosisDiagnosis Course of treatmentCourse of treatment Final diagnosisFinal diagnosis Aftercare planAftercare plan


Saying goodbye to your client is Saying goodbye to your client is inevitable.inevitable.

You will most likely have mixed You will most likely have mixed feelings when he or she leaves feelings when he or she leaves treatment.treatment.

Professional Practices: Referral & Documentation

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