TAP 21 - SAMHSA Store - Substance Abuse and Mental Health ...

Addiction Counseling Competencies
Competency 112:
Record progress of client in relation to treatment goals and objectives.
Knowledge
uX
u
Appropriate clinical terminology used to
describe client’s response to intervention
and progress made toward completing
treatment goals and objectives.
How to review and update records.
Skills
uX Preparing clear and legible documents.
u Documenting changes in the treatment
plan, client status, client response to and
outcome of interventions, level of care
provided, and discharge status.
u Using appropriate clinical terminology
and standardized abbreviations.
u Noting client’s strengths and limitations
in achieving treatment goals.
u Recording client’s response to and outcome
of interventions.
u Recording changes in client’s status,
behavior, and level of functioning.
u Noting limitations of treatment provided
to client.
Attitudes
uX Recognition of the value of objectively
recording progress.
u Recognition that timely recording is critical
to accurate documentation.
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