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Student Discussion: Sam Heastie
B.A.R.C. – Broward Addictions Recovery Center
Coral Springs, Florida
Weekly Review:
Lecture
The thing that I found most interesting about this week’s lecture was under the section titled “When To Write Notes,” which stated, “The problem with waiting to record information, or taking notes at the end of the day, is that writing long after the experience ends leads to the possibility of your memories being contaminated by information from sessions with other clients.” I agree with the lecture’s statement. It reminds me of one of my courses on cognition that discussed how human memory works and how susceptible memories are to distortion with the passage of time.
Topic of The Week:
Briefly describe the documentation type(s) that you are using in your placement.
Process and Progress notes, both, are being used in the current placement. The process notes are used for process group sessions, which are conducted at least three times per week, and the progress notes are used for individual therapy sessions, which are conducted at least once per week.
The process notes take the form of:
Group Theme (include the main idea or topic for the group):
Goals addressed: #1 ____, #2 _____, #3, etc.
Level of client participation
Affect & Mood
Stage of change
Progress towards TX plan goals & objectives
Interventions utilized during group
Recommendation for the client, and
Other recommendation and/or explanation
The progress notes use the SOAP form. Below is a sample of a not that was recently written.
Goal addressed: #1 To reduce substance use
Objective addressed: #2 To identify 3 triggers to relapsing and share them with therapist is session.
S: Client stated, “I had a difficult time controlling my craving this week”. The client felt that she would relapse once she was discharged.
O: The client appeared agitated in session as she discussed her substance use and plan to remain drug free.
A: The client explored two of her automatic thoughts that contributed to her anxiety to relapsing. She shared that seeing videos during group and hearing other clients make comments about how they felt when they were using made her think about when she used to use Heroine and that she had no control of using once she was triggered. She engaged in cognitive restructuring to help her replace these automatic thoughts with more positive strategies to remain focused on her recovery (e.g. deep breathing and thought stopping exercises). During the session, the client appeared to be in the contemplation stage of change regarding her substance use treatment. The client was open to feedback and saw the connection between her thoughts of relapsing as increasing her anxiety and agitation in session. The client was given homework to record two automatic thoughts that may occur this coming week that may increase her anxiety and utilize the deep breathing exercises discussed in the session.
P: The client will complete the homework assignment for the next session and demonstrate the deep breathing exercises in session for feedback by this writer.
Discuss the positives and negatives or any difficulties you may be having with the forms.
Training on the use of these forms that the agency uses was conducted by the clinical director, which was a pleasant experience. He demonstrated how to write the notes and how to enter them into the agency’s electronic data reporting system.
First, given my ethical responsibility to allow the client access to his records (NASW), I would allow him to see the records. However, given that there is some damaging information about him in the documentation, I would consult with him to explain what the information is and how it might be used in his best possible interest.
Second, I would document my individual session concerning the matter using the soap note format as it would reflect my clinical decision-making for self-defense.
Peer Question
When writing notes, do you think about what is said and how it’s stated given that it might be subpoenaed by a court? I do.
Reference:
National Association of Social Workers (NASW). (n.d.). Retrieved January 22, 2023, from https://www.socialworkers.org/About/Ethics/Code-of-Ethics
