Documentation Copy

Keeping up with required clinical documentation is an ethical responsibility of the peer support specialist. In addition to the administrative requirements for clinical record keeping, the peer support specialist must make sure that the content of the clinical record is clear, concise, precise and accurate. The clinical record speaks for the client in recording progress through the treatment and recovery process.

Clinical documentation is a way to keep everyone involved in the treatment and recovery process accountable. While the form and format of documentation may vary from agency to agency, the standards for good clinical documentation are consistent. Good clinical documentation provides relevant information in appropriate detail so that all persons who rely on the record for information or decision-making are able to understand what is being documented.

In the current climate where electronic health records are portable and follow the client from provider to provider in order to coordinate care, the client’s information must be presented in the best way possible to ensure quality service provision. The responsibility for accurately representing the client’s situation rests with the peer support specialist and other treatment staff rather than with the client. Computerized records should be treated in the same way as paper records with regard to having records off the agency premises.

Good Clinical Documentation is:

  • Accurate
  • Thorough
  • Timely
  • Complete
  • Signed and credentialed

The language used in clinical documentation is important. The peer support specialist should write in specific, descriptive language, use words with clear meaning, and record evidence of the senses: things seen, heard, smelled, tasted, and touched. It is important to avoid the use of judgmental or value-laden words. Good documentation fully identifies persons, places, direct quotations, and sources of information. The peer support specialist should record facts, rather than an evaluation of the facts and clearly label impressions based on observable information.

Each session with a client should have its own separate notation, unless agency policy dictates otherwise. One notation format that is used frequently by peer support specialists and other professionals is called the SOAP note. The four components of SOAP notes are:

  • Subjective – what the client reports about his or her status or condition. Usually, this is a direct quote. For example: “I do not like to talk in this group.”
  • Objective – what the peer support specialist observes or measures. For example: “Head lowered, no eye contact.”
  • Assessment – for peer support specialists, this is likely a list of client needs or referral suggestions. For example: “Client needs support in developing budget,” or “Client should see physician for chronic headache issue.”
  • Plan – describes the actions the peer support specialist will take to address client needs or the actions that the client will take to resolve the issue. For example: “Client will begin to wear a watch in order to manage time,” or “peer specialist will obtain bus passes to assist client in transportation to and from work.”

Generally, the notations in a client record are kept in chronological (date) order. Sometimes different members of the team make their notations in separate sections of the file. If a peer support specialist makes an error in a progress note, they should place a line through the error and initial it or, in the case of electronic records, they should utilize the correction method specified by the agency. If a peer support specialist is late in making a note in a client file and it will be out of chronological sequence, the note should be marked “late entry” and put in the record as soon as possible.

The client record is considered to be a legal document and the peer support specialist’s signature, whether electronic or written, means that the record is truthful, complete and accurate. This is why records must be written in ink (or electronically time stamped and dated). It is important to stick to factual observations and avoid overly subjective interpretation. When possible, using actual quotations from the client or significant others is desirable. In order to assure accurate recollection, clinical documentation should occur as soon as possible after the contact with the client.