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Barbara Jordan
Jan 26, 2011

Recordkeeping And Quality Of Care

Well, ACA blog would not believe what happened to me last week. On Friday afternoon, I received a call from a very panicked administrative director. I’d just begun working as a Clinical Supervisor at this agency. So, you can imagine my surprise. Apparently, she had just discovered that one of the counselors had not completed several case notes and discharge summaries! Wow! How could this happen?! As a certified Substance Abuse Counselor (CSAC), he should have known better. The worse part? We couldn’t contact the counselor because he is out of the country on vacation!

Now, this post serves not just as a warning to novice counselors, but also a reminder to seasoned counselors and clinical supervisors. Good intakes, assessment summaries, treatment plans, progress notes, and discharge summaries are an important part of ethical practice. They assure quality of care so that in an emergency, another provider can continue treatment. Accurate, timely documentation answers referral questions and provides referral sources with additional information when relevant. It reminds us clinicians of specific recommended courses of action or appropriate interventions taken with clients. It provides accurate information regarding the current functioning/history of clients. And, it provides baseline information for evaluating progress of clients.

This documentation is also necessary to show which services were provided and at what quality. Therefore, it is important to make notes immediately after each client session so that we are up to date on record-keeping requirements and procedures, laws, and regulations. I’m not sure how my predecessor, the clinical supervisor before me, operated. But, clinical supervisors should periodically make a random check of supervisee’s intakes, assessments, progress notes, and other documentation.

When the director and I asked another counselor on staff how this could have happened, he alluded to the issue of insufficient time given the counselors’ current caseload. I suggested that counselor/supervisees set time aside in the morning to do paperwork before meeting their first client of the day. Whenever they have a cancellation, I encourage them to use the available time for paperwork. For those who have trouble getting paperwork done due to phone and other interruptions, I direct them to ask the receptionist to hold calls for blocks of time. When I do paperwork, I close the door, explaining to co-workers that when the door is shut, I need quiet to do paperwork. I hang a sign on my door saying, “Do Not Disturb…Any Further!” It usually gets a few chuckles. Another strategy is to move to a location away from phones, co-workers, and clients such as a conference room. As a proactive measure, I save supervisees time and energy by creating fill-in-the-blank assessment summary, treatment plan, discharge summary, etc. forms to familiarize them with record-keeping requirements. These highly structured forms significantly help those who struggle with what to say, how to say it, or writing in general.

Not sure what to say in your reports? In my reports and record-keeping classes as well as in my assessment, diagnosis, and treatment planning classes, I provide students with a list of important questions to answer and examples of exemplary intakes, assessments, progress notes, etc. I also provide a completed chart that students can refer to as they create their own chart on a hypothetical client. Perhaps those of you readers who are clinical supervisors or educators, you too can provide these tools to your supervisees or students. And those of you counselors, you can request that your supervisor provide these “templates” and outstanding examples.

Many inexperienced supervisees struggle with this issue of paperwork. According to Jane Campbell, author of Essentials of Clinical Supervision, the causes include:
•Being overwhelmed by demands of client services
•Inability to organize time efficiently
•No training in how to complete paperwork satisfactorily
•Continuous changes to paperwork requirements
•Computer problems
•Supervisees’ negative attitudes about paperwork
•Supervisees’ fears of writing and perfectionism

Campbell suggests that (perhaps in your next group supervision meeting) you and your supervisees have a brainstorming session wherein you generate 1) a list of obstacles to completing paperwork and 2) a list of solutions. Have supervisees select the most workable solutions to each of them personally. Then, ask each counselor to create a personal action plan incorporating those chosen solutions. And, lastly, request that everyone take out their planners and set actual dates and times for implementation and follow-up. Be sure to reward staff for this great work and encourage them to reward themselves too.

Barbara Jordan is a counselor, counselor educator, author, trainer, and leadership coach. For more information go to

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1 Comment

  1. 1 Tequila 28 Feb
    As a grad student in the for the Clinical Mental Health Counseling, I'm reminded of what my case management instructor would say, "if it's not documented, it did not exist." Thank you for sharing this piece on the importance of documentation!!


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