Clinical Documentation and Treatment Planning Skills Report

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One of the learning goals to be achieved as part of the counseling field placement is developing an understanding of the importance of clinical documentation and treatment planning skills for each client. In this case, one will have to evaluate a client’s diagnosis to come up with a treatment plan that is likely to enhance quality of life. Clinical documentation is necessary for a client to be assured of continued care by enabling a healthcare practitioner to keep track of important treatment moments. This is necessary for a practitioner to address thought patterns and unhealthy behaviors that are likely to affect the recovery process. Having effective treatment planning skills plays a significant role in enhancing patient safety in the treatment process while also minimizing the likelihood of errors. Understanding clinical documentation and treatment planning expertise will enhance effectiveness when dealing with clients.

The first learning activity in counseling field placement will be a discussion on why a counselor has to develop measurable goals and comprehensive clinical documentation for each client they deal with. Developing measurable goals enables a health practitioner to understand their client’s growth as the therapy process continues (Riopel, 2019). Such goals play a role in minimizing stress and anxiety levels in therapists when dealing with clients since they know what they seek to achieve and what they can do to maximize success. Clinical documentation is necessary for inter-provider communication while also promoting the development of patient registry functions that can be utilized in health research. The information included in clinical documentation can be accessed by authorized practitioners when providing care to a specific client. Gaining knowledge on the importance of measurable goal setting and clinical documentation will help to promote positive outcomes when dealing with clients.

The second learning goal for counseling field placement is to address the importance of interns taking part in case consultations with a qualified therapist within the agency. Case consultations expose interns to collegiate support and wisdom which is necessary for them to relate with their clients in situations that can be challenging (ASPM, 2022). Having a qualified therapist in counseling field placement promotes a safe space for interns to share their thoughts and feelings. Such consultations are necessary to enhance case conceptualization abilities for three adolescent clients. An intern with case conceptualization can easily understand the issues that a client presents while also acting as a guide to the counseling process (Sperry & Sperry, 2020). A counselor with conceptualization abilities can develop an effective treatment plan while also enhancing the likelihood of goal achievement.

Another learning activity that will be part of the counseling field placement is having a discussion on the importance of case details. The discussion will have to address client evaluation, diagnosis, treatment modalities, and procedures with a licensed clinician who is not the field placement supervisor. The discussion will have to take place within two weeks of each intake session. Gaining such knowledge will promote effectiveness when dealing with clients to enhance their quality of life. An understanding of important case details will play a role in promoting effective case management. A counselor with effective case management can minimize prescription errors, resource misuse, and patient readmission rates. Understanding the importance of case details will help to promote effectiveness when dealing with different clients since one will understand the issues they are dealing with.

References

ASPM. (2022). Case consultations. Aspm.org.au. Web.

Perry, J., & Perry, L. (2020). Case conceptualization: Key to highly effective counseling. Counseling Today. Web.

Riopel, L. (2019). . Positive Psychology.com. Web.

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