The Addiction Progress Notes Planner. Группа авторов

the Joint Commission, Council on Accreditation, Commission on Accreditation of Rehabilitation Facilities, and National Committee for Quality Assurance.

HOW TO USE THIS PROGRESS NOTES PLANNER

      This Progress Notes Planner provides a menu of sentences that can be selected for constructing progress notes based on the behavioral definitions (or client's symptom presentation) and therapeutic interventions from its companion Treatment Planner. All progress notes must be tied to the patient's treatment plan—session notes should elaborate on the problems, symptoms, and interventions contained in the plan.

      Each chapter title is a reflection of the client's potential presenting problem. The first section of the chapter, “Client Presentation,” provides a detailed menu of statements that may describe how that presenting problem manifested itself in behavioral signs and symptoms. The numbers in parentheses within the Client Presentation section correspond to the numbers of the Behavioral Definitions from the Treatment Planner.

      The second section of each chapter, “Interventions Implemented,” provides a menu of statements related to the action that was taken within the session to assist the client in making progress. The numbering of the items in the Interventions Implemented section follows exactly the numbering of Therapeutic Intervention items in the corresponding Treatment Planner.

Each item list begins with a few keywords in bold type. These words are meant to convey the theme or content of the sentences that are contained in that listing. The clinician may peruse the list of keywords to find content that matches the client's presentation and the clinician's intervention. It is expected that the clinician may modify the prewritten statements contained in this book to fit the exact circumstances of the client's presentation and treatment. To maintain complete client records, in addition to progress note statements that may be selected and individualized from this book, the date, time, and length of a session; those present within the session; the provider; the provider's credentials; and a signature must be entered in the client's record.

A FINAL NOTE ABOUT PROGRESS NOTES AND HIPAA

      Federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) govern the privacy of a client's psychotherapy notes, as well as other protected health information (PHI). PHI and psychotherapy notes must be kept secure and the client must sign a specific authorization to release this confidential information to anyone beyond the client's therapist or treatment team. Further, psychotherapy notes receive other special treatment under HIPAA; for example, they may not be altered after they are initially drafted. Instead, the clinician must create and file formal amendments to the notes if he or she wishes to expand, delete, or otherwise change them.

      Does the information contained in this book, when entered into a client's record as a progress note, qualify as a “psychotherapy note” and therefore merit confidential protection under HIPAA regulations? If the progress note that is created by selecting sentences from the database contained in this book is kept in a location separate from the client's PHI data, then the note could qualify as psychotherapy note data that are more protected than general PHI. However, because the sentences contained in this book convey generic information regarding the client's progress, the clinician may decide to keep the notes mixed in with the client's PHI and not consider it psychotherapy note data. In short, how you treat the information (separated from or integrated with PHI) can determine if this progress note planner data is psychotherapy note information. If you modify or edit these generic sentences to reflect more personal information about the client or if you add sentences that contain confidential information, the argument for keeping these notes separate from PHI and treating them as psychotherapy notes becomes stronger. For some therapists, our sentences alone reflect enough personal information to qualify as psychotherapy notes, and they will keep these notes separate from the client's PHI and require specific authorization from the client to share them with a clearly identified recipient for a clearly identified purpose.

ADULT-CHILD-OF-AN-ALCOHOLIC (ACA) TRAITS

      CLIENT PRESENTATION

      1 Raised in an Alcoholic Home (1)*The client described a history of being raised in an alcoholic home but denied any effects of such an upbringing.The client described a history of being raised in an alcoholic home but was uncertain about how this affected their emotions.The client described a history of being raised in an alcoholic home and identified effects, including emotional abandonment, role confusion, abuse, and a chaotic, unpredictable environment.The client processed issues related to being raised in an alcoholic home, including emotional abandonment, role confusion, abuse, and a chaotic, unpredictable environment.

      2 Unresolved Childhood Trauma (2)The client described a history of childhood trauma caused by family addiction but denied any effects of this behavior.The client described a history of childhood trauma caused by family addiction but was unsure of any effects of this behavior.The client described a history of unresolved childhood trauma caused by family addiction.The client resolved the feelings associated with the childhood trauma caused by family addiction.

      3 Inability to Trust and Share Feelings (3)The client revealed a pattern of extreme difficulty in trusting others, sharing feelings, or talking openly about self.When sharing openly with others, the client experiences feelings of anxiety and uncertainty.As the client has begun to work through adult-child-of-an-alcoholic (ACA) concerns, they have reported feeling less anxiety or uncertainty when sharing emotional concerns.The client no longer experiences anxiety or uncertainty while sharing emotions.

      4 Overconcern With Others (4)The client described a pattern of consistently being overly concerned with taking care of others, resulting in failure to care for self.The client identified a need to reduce focus on others’ functioning and to replace this with a focus on their own functioning.The client has been able to balance the focus on others’ functioning with a focus on their own functioning.

      5 Passive Submission (5)The client described a history of being passively submissive to the wishes of others, in an effort to please them.The client tries to ingratiate self to others by being submissive to their wishes.The client acknowledged the need to become more assertive but has struggled to implement the assertiveness.The client is being self-assertive and setting healthy limits.

      6 Clings to Destructive Relationships (6)The client described a pattern of clinging to destructive relationships in order to avoid interpersonal abandonment.Hypersensitivity to abandonment has caused the client to maintain relationships that are destructive.The client has acknowledged interpersonal abandonment as a significant issue.The client accepts interpersonal conflict and is changing destructive relationships.

      7 Tells Others What They Want to Hear (7)The client described a pattern of disregarding reality in order to present information so that others will be pleased.The client identifies situations in which the client has been able to be more truthful.The client described the acceptance of others in response to the client's increased truthfulness.

      8 Feels Worthless (8)The client verbalized seeing self as being worthless and that disrespectful treatment by others was normal and expected.The client has begun to develop a more positive image of self-worth and is more expectant of positive treatment from others.The client clearly identifies improved self-image and insists on being treated in a respectful manner.

      9 Experiences of Abandonment and Abuse (9)The client described feeling unwanted, unimportant, and unloved because of experiences of abandonment and abuse.The client has reduced feelings of being unwanted, unimportant, or unloved.The client verbalized feeling wanted, important, and loved in relationships with others.

      10 Panic When Relationships End (10)The client described a pattern of strong feelings of panic and helplessness when faced with being alone as a close relationship ends.The client described a chronic pattern of precipitating problems in a relationship because of feelings of panic and helplessness when faced with the possibility of friction in a close relationship.The client has become more