All standard addiction counseling progress notes should include the date and location, as well as a brief narrative of the counseling session, reports Magellan Health. The counselor's writing should be concise and legible, providing adequate details about the session without violating the privacy of other patients, according to Current Psychiatry.
The counselor should provide details on the client's strengths and behavior during the session, reports Magellan Health. The notes should thoroughly explain the treatment plan, according to Current Psychiatry.
Counselors must include substance abuse assessments and suicide risks in the progress notes, reports Magellan Health. Counseling notes should contain clear details of treatment plans for patients who appear suicidal, according to Current Psychiatry. If counselors decide to discontinue suicide precautions, they should document their reasons for doing.
Counselors should not mention other patients by name if they are not essential to the report, as this is a breach of their privacy, states Current Psychiatry. If the counselor chooses to disregard the advice of other medical professionals when prescribing medication, he should explain his reasons in the progress notes.
Counselors should always portray concern and respect for the patient when writing progress notes, according to Current Psychiatry. For example, instead of writing that the patient is a liar, the counselor can write that the patient's version of events is different from police records.