Clinical Notation: Documentation for clients in treatment - CASAT

Changing the Treatment PlanIf you are making major changes to the treatment plan, suchas a change to the course of treatment, then you must do areview as well.For example, if you refer a client out to a local adult educationcenter to get a GED and they succeed, you would need tochange the treatment plan to reflect that progress.At that time, a review may not be necessary because thismilestone may not affect the course of the client's treatment.However, if you discover a new problem as you build yourrelationship with your client that contributes to theirsubstance use or causes a change in the course of treatment,you would edit the treatment plan to include that problemand you would also do a treatment plan review.