This course has emphasized the importance of proper documentation as a critical skill of the substance abuse counselor. This is true for many reasons. A good, clear treatment plan will serve as a guide for future case management services for the client. Most often, there are several people involved in helping a client with addiction issues because addiction is often a medical, psychological, and social disease that requires an interdisciplinary approach. Clinical documentation should be written with the understanding that the information may be read, with proper consent, by social workers, medical professionals, and lawyers (or others in a courtroom) and could inaccurately portray the client in a favorable or unfavorable way. There is a fine line with documentation that good clinical supervision and experience help to unveil. Accurate documentation is at the heart of all the core functions!
SMART goals, ASAM’s criteria, and DAP and SOAP notes provide structure to documentation to ensure that the necessary and appropriate clinical information is recorded. This journal assignment asks you to consider the importance of documentation to the client and to the system attempting to help the client, as well as the value of the above tools for doing it right.
In your journal assignment, answer this question: Why is it important in the field to document all information accurately using the correct formatting and style? In 3 paragraphs, discuss this importance from the perspectives of the client, the counselor and other treatment professionals, and the larger system. The “system” includes the serving organization/institution, employers, insurance companies, medical professionals, law enforcement, lawyers, judges, and the courts.
