PROGRESS NOTES

The Recovery Works program shall document the services received by the client and document chronologically the observations of the client’s clinical course of treatment which includes the client’s;

  1. response to treatment and

  2. progress toward achieving individual goals and

  3. desired outcomes.

Progress notes shall be documented by the staff members assigned primary responsibility for the client’s care and shall be legible and recorded in the client’s chart.

Progress notes shall be recorded as applicable:

  1. At a minimum a daily note will be recorded for enrolled clients in attendance or;

  2. Following any clinical contact with a client undergoing detoxification or narcotic treatment or;

  3. Whenever there are clinical face-to-face contacts with the client

  4. Whenever a client is observed to engage in a behavior which may effect a change in the treatment plan.

  5. Immediately following the use of any emergency safety intervention.