Documenting the use of EBPs in client

charts

• Nicole Ibarra, MFT, Managing Director

• Chris Kernes, MFT, Clinical Director
 The Golden Thread
Here’s an example of how you can
follow the Golden Thread…
Assessment
Assessment Example:
During Jane’s assessment, she disclosed a history of using alcohol
regularly to intoxication along with a history of trauma.

Diagnosis Diagnosis Example:

Jane was diagnosed with Alcohol Dependence and PTSD.

Treatment Plan Example:

One of Jane’s treatment plan goals is to:
Develop some coping skills to help her deal with
Treatment Plan her PTSD symptoms rather than drinking.

Progress Note Example:

Jane attended Coping Skills group
today to work on her treatment plan
goal of building more coping skills to
The Golden Thread is the connection between the help her deal with her PTSD
various parts of treatment that you describe in your symptoms. Jane worked on identifyin
documentation. Your documentation should tell the
Progress Notes some of her personal triggers. She
story of each client’s unique treatment episode with also shared that she really wants to
the thread of connection woven through the story. learn about what she can do to help
herself feel better rather than
The thread of documentation establishes a written,
drinking.
egal record of the course of treatment. It provides
the information needed for both guiding the
treatment process and for billing purposes.
 Documenting your one-to-one
focusing on goals
• Progress notes tell a client’s treatment story and give the
clinician credit for the incredible work that happens in a
treatment setting.

• All Progress Notes must include:

• 1. The topic of the session

• 2. A description of the client’s progress on treatment plan
challenges, goals, action steps, objectives and/or referrals
• 3. Information on the client’s attendance
• 4. Information on EBP’s that you used with client
 Things to Include in the Note
• Direct quotes from the client
• Client’s affect, mood, overall
presentation
• Observations regarding
motivation
• Report on symptoms and or
symptom relief
• Action items
• Agreements
• Evidenced-Based Practices Used
• Coping skills discussed
• Homework

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 How to Properly Link TX Plan to Progress
Note
• Do’s • Don’ts

• Use verbiage from the treatment • Restate the entire TX Plan in the
plan in every progress note. progress note
• Give updates on progress, • Don’t feel like the client has to
setbacks, obstacles, coping skills, have reportable progress with
delays, appointments, etc. their goals; the note has to be
• If a client is struggling to meet a related to the goals and is more
goal, discuss the path that was about the status and process.
taken in the session and ideas • Don’t think that there isn’t room
that came up along with a game in the session for other topics to
plan. be discussed.

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 EBP’s and Standards of Care
• ODS Requires a minimum of 2
of 5 listed EBPs per program:
Motivational Interviewing,
Cognitive-Behavioral Therapy,
Relapse Prevention, Trauma-
Informed Treatment, and
Psycho-Education
• Standards of Care require all of
these, plus more. Standards
of Care are now our Practice
Guidelines, the standards by
which we require all
contracted providers to abide.

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Documenting the EVB in the chart
• Discuss the intervention from the EBP used and client’s response.
Examples:

• MI Ruler, Decisional Balance Worksheet, Change Plan (Motivational

Interviewing)
• Thought Record, Cognitive Distortion Worksheet (CBT)
• Wise-mind, Chain Analysis, Emotion Regulation Module, Diary Card (DBT)
• Boundary Setting, PTSD Taking Back Your Power (Seeking Safety)
• The Aggression Cycle (Anger Management, SAMHSA)
• The Many Parts of You (Training Our Minds In, With And for Compassion)
• Discipline That Makes Sense (S.T.E.P. The Parent’s Handbook)

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Individual Progress Note Example
Individual Progress Note 1:

(P) Client reports experiencing increased cravings to use Methamphetamines this week. “I
thought it would get easier as time went by, but I can’t stop thinking about it. I even had
a dream that I left program to use.”

(I) Counselor reviewed treatment plan goal under dimension 5 to “increase and better utilize
coping skills to avoid relapse.” Asked the client to provide a more detailed description of
the physical and psychological aspects of craving and inquired what coping skills had
been employed to avoid relapse.

(R) In addition to being preoccupied with thoughts of using and the recent dream, the client
reported a “nervous” sensation in his stomach. Initially he had a hard time identifying
any coping skills he used, however he was eventually able to say that he had been using
the Observe and Describe skills he learned in mindfulness group to become more aware
of cravings. “In the past, my relapses just kind of snuck up on me,” he said. Now I’m
using mindfulness so there are no more sneak attacks.”

(P) Introduced a modified diary card to the client and encouraged him to use it to daily track
and rate the intensity of his cravings and the use of skills to manage them. Requested that
he bring the diary card to next week’s individual session so we can continue to work on
this issue.

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Individual Progress Note Example
Individual Progress Note 3:

(P) Client requested that we focus this session on the decision he needs to make regarding
whether or not to start Suboxone to treat his opiate addiction. In accordance with his
dimension 5 treatment plan goal of exploring MAT interventions within 30 days of
entering treatment, the client underwent a physical examination and discussed MAT
interventions with his physician. The client is reporting some ambivalence about
potentially starting Suboxone.

(I) Engaged in empathic listening and assisted the client in completing a decision balance
worksheet (Motivational Interviewing) of utilizing Suboxone as a tool in his recovery
process. The client identified one advantage as being that he has relapsed during
several other attempts at recovery and he speculates that medication may help him
avoid that in the future. One disadvantage he identified was that he wants to become
drug-free and fears becoming dependent on the Suboxone.

(R) Client decided that the pros outweigh the cons and stated he will proceed with a
MAT intervention. He made an appointment for later this week during our session.

(P) During our next individual session, we agreed we would discuss his experience with
the medication as well as discuss previous relapses to assist him to identify internal
and external triggers and skills to manage them.

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 Group Progress Notes
Group Progress Notes are individual narrative summaries
and shall include all of the following:

• The topic of the session (include

highlights of the group session).
• An individual description of the
beneficiary’s progress in group
and on their treatment plan problems,
goals, action steps (interventions &
objectives) and/or referrals as it relates
to the group topic.
• Therapist/Counselor who facilitated the
group counseling session must record
the progress note for each beneficiary
who participated in the group.
• Therapist/Counselor who facilitated the
group counseling session must record
the evidenced-based practices that
were used and provide concrete
examples.
Strategies for Individualized Group Notes

• Have the client fill out a short form, at the end

of a group, on what they worked on.
• Having a routine check-in/check-out that
includes asking about treatment plan goals
• Have a reflection activity at the end of every
group that asks clients to discuss what goals
they are taking away from today’s group.
• Use EVB’s and document the client’s responses
to the intervnetions.
 Group Progress Note Example
(Mindfulness, DBT)
• A client has a treatment plan goal to manage cravings and urges to use
methamphetamine. He attends a Mindfulness group that taught and
practiced mindfulness skills.
Group note: Treatment Plan goal: Manage cravings and urges to use
Methamphetamine.
Client participated in a DBT Mindfulness group where he learned how to
observe and describe thoughts, emotions, physical sensations, and behaviors
associated with substance cravings. The group used the, “Taking Hold of Your
Mind, Handouts 1-3: “What Skills” from the DBT Manual.” He practiced
noticing these when present and accurately describing them as elements of
craving. He endorsed an understanding that becoming more aware of his
cravings will make it less likely that he will unthinkingly act on them. “My
body is telling me it wants to use, but I don’t have to give it what it wants,” he
said.

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 Group Progress Note Example,
Mindfulness, DBT
Group Note: Youth
Today, DBT group taught the “How” mindfulness skills of one-mindfully, non-judgmentally,
and effectively. The advantages of avoiding multi-tasking in the service of being more fully in
the present moment; eliminating value judgements; and choosing adaptive responses even in the
face of unfairness was discussed.
During the group, related to the effectiveness skill the client gave an example of a situation that
happened to him at school. Relating to his dimension 3 treatment plan goal to learn skills to
manage anger, he said that another kid accused him of something he did not do. Staff attempted
to hold him accountable and requested that he apologize to the other kid. He refused and
became argumentative and verbally threatening. “I kind of lost it,” he said. “I mean, the other
kid totally exaggerated what had happened and they were giving me consequences based on lies.
I don’t think that’s fair and we shouldn’t have to put up with that.” This facilitator asked what
happened to the client as a result. He reported that he was suspended from school for three days.
This facilitator pointed out that the suspension could have been avoided if the client engaged the
“effectively skill, respectfully denying engaging in the problem behavior but accepting the initial
consequence that was less severe than the three-day suspension.

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 Group Progress Note Example, Anger
Management
 Group Session Activities - Started group with breathing exercises; reviewed group rules.
Focus of Group: Session 4, Discussed the 3 phases of an anger from The Aggression
Cycle episode which are escalation, explosion and post-explosion. Clients learned one
of the primary objectives if anger management is to keep from reaching the explosion
phase. Presented and discussed the anger meter and the aggression cycle chart.
Discussed and lead Muscle Relaxation exercise. Assigned HW: monitor and record
highest level of anger on the anger meter, identify the event that made them angry,
cues associated with the anger-provoking event, and the strategies they used to manage
their anger in response to the event. Clients to practice progressive muscle relaxation
once daily during the coming week. Clients to continue to develop their anger control
plans.

 Session Results (individualized portion) – CT participated in anger management group

related to his treatment goal of reducing the frequency and intensity of his anger
outbursts instead of relying on substances to manage negative emotions. CT stated he
thought “this information is useful because it might help me control my anger better
before it becomes really out of control.”

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