The purpose of this post is to provide support surrounding the topic of documenting our clients’ symptomatic picture. Most of the forms we utilize within the documentation realm of our field, will generally ask what the current symptoms are that your client is presenting with. It’s important to note that there are always withdrawal and other symptoms to document throughout a client’s treatment episode. These symptoms generally move from physical features, to acuity found within the mental status. When we are looking to obtain the necessary information needed for continued stay, we must be sure to ask most questions within an open-ended manner, removing the client’s ability to answer “yes” or “no”, and thus minimizing the client’s ability to under-report their symptoms.
PHP: Most of our clients within the PHP realm will be coming in with limited sobriety. Assuming that they meet criteria for PHP, they should be presenting with some of the following: gastrointestinal upset, poor appetite, sleep disturbances, restless legs, body aches, headaches, mild sweats, nausea, relapse nightmares (waking up with taste of drugs or ETOH in mouth), etc. There is a difference between asking a client, “are you experiencing any sleep disturbances?” and prompting a client with, “tell me about your sleep patterns.” Open-ended questioning in this regard will allow the client to provide the clinician with a narrative, to which the clinician can then make their determination upon whether or not a lack of sleep or the presence of nightmares are impacting the client’s daily functioning.
The goal of any treatment episode is to decrease symptoms and increase functioning, which should be documented as the client progresses through treatment. Although these symptoms decrease throughout the RTC stay, we then look to home in on the acuity found within the client’s mental status, which will get documented all the way through their discharge. This is detailed below.
IOP/OP: Questions surrounding what, if any symptoms, to document at these levels of care are common, given that the client has likely stabilized within their physical withdrawal symptoms. It is at this time that we must start using our assessment to obtain the necessary information to rationalize and document the need for continued stay.
Examples of symptoms at these levels of care that help in relaying the need for continued stay are: cognitive distortions, glorification of past use, irritability, anxiety, passive SI, physical manifestation of fear and anxiety, romanticizing of post-discharge moderated using or drinking, and low ADLs. Low ADLs, such as being malodorous or disheveled, speak to the nature of the client’s inability to keep up with basic daily responsibilities. Moreover, documentation of low ADLs help relay the reasonable foreseeability behind a client being unable to effectively manage their own medications and practice emotional regulation skills for the purpose of relapse prevention.
Lastly, the identification of symptoms is only as valuable as to which the treatment plan has been developed to address these symptoms. Our documentation of symptoms should be followed up by speaking towards the plan and goals. An example of this statement might be something along the lines of: "The treatment provided is leading to measurable clinical improvements in the symptoms and/or behaviors that led to this admission and a progression toward discharge from the present level of care, but the individual is not sufficiently stabilized so that he/she can be safely and effectively treated at a less restrictive level of care."
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