The Importance of Documentation

September 30, 2012

Documentation is not simply a chore. Indeed, documentation is one of the most important parts of a successful addiction counselor’s treatment program. Unfortunately, many counselors, both new and veteran, do not look at documentation with the respect and attention that it needs.

Some seasoned addiction counselors (and documentation skeptics) will posture that over the years or decades that they’ve counseled clients, they never once had to refer back to their documentation in order to answer a question or accusation. Many also believe that documentation is not much more than a distraction from the real purpose of counseling – clients’ recovery from substance abuse and addiction.

Documentation has a profound effect on the addiction industry as a whole and deserves the respect of counselors and administrators alike. Documentation is beneficial to all involved – the facility, the counselor as well as the client and their family.

For the client, documentation offers concrete evidence of the direction of their treatment that they can refer back to when they want to evaluate their own treatment plan or how their treatment is progressing. It allows the client and their family members, if allowed, to track the progress of their treatment. Documentation also helps the counselor because there will be times when written notes will be referred to as the treatment plan is modified or follow-up protocols are developed. Further, when counselors are in need of help from other counselors or a supervisor, documentation can help everyone understand the context of the issues at hand. For the facility, if there is a legal dispute or any question about the treatment being provided to a client, accurate documentation can go a long way in determining what exactly transpired and the context of the event.  Further, a third-party such as a governmental auditor, a judge or a police officer is more likely to receive the information they need to make a judgment with complete and accurate documentation.

Documentation is extremely important part of the business of counseling and every counselor must understand that documentation will ultimately help them, despite sometimes pulling them away from their hands-on work.

Learn more about our documentation course.

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