Forms & Documentation

While there are multiple ways to document, the easiest and most efficient is narrative note taking, ie. taking notes during the session verbatim as you and the client interact. Most EHR's have a scan upload feature. Its fast, easy and note submission takes 5 minutes or less. We recommend taking a class on documentation with your local board for CEU's (continuing education units). NEVER give medical or legal advice. Practice within your scope. Notes should always be unique to the client, even in groups.

Always apply ASAM when working with state insurance. Get training in ASAM if you are not familiar. The ASAM manual can be purchased online.  The Asam Criteria is treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions 3rd ed. Edition. It's important to learn it and use it in your work.

There is no one way to document, try several and see what fits you and your flow during sessions. Remember, go through the paperwork with the client, a proper intake is informed consent and going through the biopsychosocial. Anything you write down becomes permanent record. Take good notes but don't overdo it (in case notes are subpoenaed, you want the client to be protected).