PCN-162 Group Documentation Requirements

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Grand Canyon University *

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162

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Chemistry

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Dec 6, 2023

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1 Group Documentation Requirements Brandi Parks College of Science, Grand Canyon University PCN-162 Professor Starla Huckeba July 17, 2022

2 Group Documentation Requirements Documentation is a very crucial part of counselling and group therapy, it aids in the recovery and continuing of care for clients (Bradshaw et al., 2014). Documentation requirements are put into place to protect both the client and the counselor, and include things such as clinical decisions referrals, treatment plan, assessment, and progress that the client has made (Bradshaw et al., 2014 as cited in Mary et al., 2007). The documentations that are required for group therapy are consent for treatment, release of information, treatment plan including goals for treatment, clinical or SOAP note along with a discharge plan. The first documentation required in group therapy is consent for treatment or otherwise known as informed consent. This document legally gives permission from the client for treatment of medical or psychotherapy procedures and therapy (Fallon, 2006). The purpose of an informed consent is to make sure the client has a full understanding and knowledge of the procedure or therapy including all of the risks and benefits, it provides the client with all the information they need to know about the group, the purpose of the group, confidentiality limits of the group, any possible fees, and the right that the client has to refuse services as well as any other involvement such as court, DCFS, probation and parole etc. (Barnett, 2021). The ethical and legal requirements when providing a client with informed consent documents are that the consent must be given voluntarily by the client, ethically as counselors we must ensure the client’s understanding of the consent and the choices that they have (Barnett, 2021). Once the client gives consent then there will be release of information. The second document that is crucial for group therapy and clients is a release of information. The release of information document allows counselors and therapists to share information with others regarding previous services, services that are concurrent with the client’s

3 issues at this point, and also allows the counselor to share information to other physicians, or any legal persons associated with the client’s case such as lawyer, DCFS, or probation and parole (Bradshaw et al., 2014 as cited in Mary et al., 2007). There are two purposes of the release of information, one is a release to obtain information from others and another release to provide information to others about the client (Bradshaw et al., 2014). Counselors and therapists have many ethical, professional, and legal obligations when it comes to the release of a client’s information. They are legally and ethically responsible to make sure that a signed release of information is filed when discussing the client with other associated people and they are required to only discuss confidential information for scientific and or other professional purposes and only the specified information can be shared or obtained (Bradshaw et al., 2014 as cited in APA Ethics Code, 2002). Once the release of information document is complete, the focus is then put on the treatment plan and goals. Treatment plans include documented diagnoses, symptoms that should be treated, treatment goals and approaches to treatment that are used (Bradshaw et al., 2014). The purpose of a treatment plan is to ensure that the counselor or therapist has set a confirmed course for treatment. Ethical or legal issues that may come up with treatment plans are poor or absent plans, failure to document any communication with the client about the treatment plan, vague or irrational goals for treatment and poor documentation of symptoms or issues of the client (Bradshaw et al., 2014). Once a treatment plan is put into place then comes the clinical or SOAP notes. Clinical notes are written records of personal communication between the counselor and client that includes content of discussions, techniques or interventions that were used by the counselor, comments and responses from the client, assessments, concerns, and the client’s

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4 progress toward treatment goals (Bradshaw et al., 2014). SOAP is a format that stands for subjective, objective, assessment, and plan, it is a format that is used to help providers to document, assess and validate therapeutic decisions for treatment (Bradshaw et al., 2014). SOAP is more of like a framework that provides structure and organization to the way a counselor or therapist document their clinical notes. Providers have ethical and professional standards as well as legal obligations to take accurate, detailed, and informative notes and information on the client. The last document that is required in group therapy is the discharge plan. Coming up with a discharge plan is a crucial part of recovery for the client. Discharge planning should begin at the onset of treatment, it helps clients, and their families prepare to work through the rollercoaster of recovery (Motley, 2018). Key components of a discharge plan include counseling, medication, family support, support groups such as AA or NA, accountability, a plan to address relapse, and living arrangements to ensure safety of the client (Motley, 2018). Any time that a discharge plan is documented it must meet all ethical and professional requirements concerning who the client’s information and file can be shared with any violations could result in legal issues because of confidentiality. When a counselor is treating a client or group in therapy there are certain requirements and documentation that is required to ethically, professionally, and legally help these clients to change their behaviors and remain healthy and sober. It is crucial that counselors or therapists understand the documentation requirements when involved in group therapy. References

5 Barnett, J. (2021). Informed Consent in Clinical Practice. Retrieved from https://societyforpsychotherapy.org/informed-consent-in-clinical-practice-the-basics-and- beyond/ Bradshaw, K. M., Donohue, B., & Wilks, C. (2014). A Review of Quality Assurance Methods to Assist Professional Record Keeping: Implications for Providers of Interpersonal Violence Treatment. Aggression and violent behavior , 19 (3), 242–250. https://doi.org/10.1016/j.avb.2014.04.010 Fallon A. (2006). Informed consent in the practice of group psychotherapy. International journal of group psychotherapy , 56 (4), 431–453. https://doi.org/10.1521/ijgp.2006.56.4.431 Motley, C. (2018). How to Make a Discharge Plan When Your Child Leaves Addiction Treatment. Retrieved from https://drugfree.org/article/how-to-make-a-discharge-plan- when-your-child-leaves-addiction-treatment/