The narrative should describe the following elements:
- Client’s symptoms/behaviors
- Client’s strengths
- Provider’s intervention and the client’s response to the intervention
- Barriers to treatment and interventions to address non-compliance
- Plan of subsequent services
- Progress towards treatment plan goals and objectives
- Description of significant changes in client’s status
Recommended Demographic Data to include:
- Member Name
- Member ID
- Service/Type of Session
- Location of Service
- Session Start
- Session End
- Others Attending/ Relationship to Client
- Next Scheduled Appointment
Techniques for Documenting the Narrative:
- Problem: Describe what the problem is that brought the client through the door or the focus of the session. This can also be directly related to one of the treatment goals.
- Assessment: What are your general observations about this client?
- Intervention: What did you do?
- Plan: What will you do next?
- Subjective: How does the client describe their problem? It is recommended that a quote or statement from the client describing their subjective description of the problem should be included.
- Objective: What did you observe about this client? This portion should be written in quantifiable and document mental status and physical and psychological responses to the process (e.g., mental status exam). The phrase as evidenced by is helpful to document observations.
- Assessment: What is your impression about/of this client? This section summarizes the provider’s clinical thinking regarding the client. This should include an ongoing risk and substance abuse assessment.
- Plan: What is your plan with this client? Discharge planning should begin at the initiation of treatment and occur on a continuous and ongoing basis. Natural community supports should be considered. Document the date and time of the next scheduled appointment.
It is important to include the following information on a continuous and ongoing basis:
- Suicide/risk assessments
- Substance abuse assessments
If safety needs are identified, documentation should support that the provider took measures to ensure the safety of the client and others (e.g., notification of appropriate agency/authority, assessment for access to weapons).
Documentation should also verify coordination of care with relevant providers when physical, psychiatric, or substance use conditions are identified. Signed Authorization for Use/Disclosure Forms should be include in the record for these providers.