5-2 Journal: Documentation
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5-2 Journal: Documentation
HSE:350 Substance Use: From Screening
Southern New Hampshire University
Wanda J. Prince
February 6, 2022
5-2 Journal: Documentation
The Client
"Incorrect documentation is often worse than no documentation."-Bertrand Meyer.
Documentation is an essential part of human services work and especially substance abuse
counseling. Proper and accurate documentation is especially important for the client. Proper and
accurate documentation is important for the client because this allows them to keep an accurate
and detailed account of their addiction and treatment progress. Proper and accurate
documentation allows a client to monitor their own progress and can even help them to become
more involved in their own treatment planning. Documentation can also be helpful for a client to
recognize triggers and analyze patterns with their addiction.
The Counselor
Proper and accurate documentation is equally if not more important for the substance abuse
counselor. Proper and accurate documentation can serve as a reference to look back on for the
counselor. This can be especially useful when making diagnosis' and when looking for things
like behavioral patterns and triggers. Proper and accurate documentation is also essential for a
counselor when they are working with a client to produce an effective treatment plan. Proper and
accurate documentation can also serve as a reference point for a counselor if there are ever any
discrepancies between the client and the counselor. For example, if a client says that they said
something that they did not say or if they accuse the counselor of saying something or vice versa
accurate and proper notes and documentation can help to clear up these types of
misunderstandings in a non-confrontational manner. It can also serve as a point of reference to
show that the counselor is providing accurate and ethical services to the client.
5-2 Journal: Documentation
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Other Treatment Professionals and "The System"
The main way that substance abuse counselors communicate with a client' other treatment
providers and the various agencies that make up "the system" is through proper and accurate
documentation. Documentation allows for counselors to compare notes and share information
per HIPPA regulations. "The system" is made up of employers, insurance companies, medical
professionals, law enforcement, lawyers, judges, and the courts. Documentation is important for
agencies like insurance companies because it can help them to ensure that the way a client is
being billed is accurate and correct. It is important for agencies within the criminal justice system
because it can help them to understand what is going on with a person if that person happens to
end up in a situation that lands them in the court and criminal justice system. Proper and accurate
documentation is an essential key to communication for all these agencies and can help avoid
issues that could arise if there were not any type of documentation available.