1 Module Five Journal: Documentation Suzi Perez Southern New Hampshire University HSE-350: Substance Use: From Screening Dr. Nuzolo June 2022 2 Module Five Journal: Documentation Client Perspective: When a client is seen by a counselor, one of the counselor’s duties as a counselor is to maintain reliable and accurate reports and records regarding the client’s treatment and progress. Often a counselor will let the client know they will be taking notes to keep “things straight,” which will soothe any concerns the client may have (Herdman, 2021). However, if a client continues to show concern about the record keeping, it might be an indication that the client may be a dual diagnosis, and these concerns may be characteristics of paranoia or a personality disorder. For example, the exaggerated fear of what the counselor may be writing about in the reports (Herdman, 2021). Counselor Perspective: To demonstrate sufficient skills in record keeping and reporting is key to being an effective substance abuse counselor. The accuracy and efficiency of a counselor’s records, from assessment to treatment plan provide other care providers insight to how well a client is doing, or if another counselor fills in, accurate notes will allow for continued progress. Additionally, when counselors maintain their records on their clients it reduces the risk of liability, especially if an audit is to be performed. If this happens, and it is determined the counselor has not kept adequate notes they could lose their license to counsel. According to an article by the National Institutes of Health (2018), say that good recording practices are necessary for effective patient management. System Perspective: This is where adequately kept records regarding a client is used as the main way of communication between the counselor and other various agencies the client may be involved with. Unfortunately, often clients seek treatment and will have many other agencies they are dealing with. That is why 3 communication, such as reliable records from a counselor are important. For example, these other agencies can include employers, other medical professionals, probation officers, and more. It is through the reliable records that the counselor keeps, that ensure the client is receiving the appropriate care, their treatment is being billed appropriately, and so on. 4 References Implementing the WHO Stop TB Strategy: A Handbook for National Tuberculosis Control Programmes. Geneva: World Health Organization; 2008. 3, Recording and reporting. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310761/ Herdman, J. (2021). Global Criteria: The 12 Core Functions of the Substance Use Counselor (Eighth). Herdman, John.
