This is the fourth in a series of five blog posts designed to inform counselors about the STEPs method for taking progress notes – a method that is systematic, efficient and effective.
The third step in the STEPs format for progress notes is the “E” – the EVALUATION section of the progress note. Evaluation involves a few different areas regarding the client’s diagnosis and progress in therapy.
First, it is important for the therapist to assess the client’s level of engagement in therapy. In the “E” section of STEPnotes, this would mean selecting options such as the client being engaged in therapy, open, guarded, minimizing or stuck. The goal with this part of the evaluation is to ascertain if the client is working towards their counseling goals or if something is occurring that inhibits the counseling process. Also, does the client’s response to therapy change with each session or is the client relatively engaged in the same manner each session? This part of the STEPs reveals the type of relationship and trust established between the therapist and the client. The therapeutic relationship is a central component to successful counseling. If a client becomes unengaged or guarded after having exhibited trust towards the counselor it is vital to note when this occurred and discovering, if possible, what caused the change in the relationship. Once trust is established, the counselor can work effectively.
Other issues regarding the evaluation of a client’s engagement in therapy are related to the client’s level of functioning. For example, a client may have difficulty engaging due to psychosis, a medical condition that exacerbates cognitive problems, or a lack of mental capacity. This section of the STEPs helps the counselor identify critical aspects of the counseling session, which in turn allows the counselor to establish future counseling needs and approaches.
EVALUTION also needs to include an assessment of the client’s current level of functioning. STEPnotes has developed a scale that runs from 1 to 10, with 1 being very poor functioning and 10 being optimal functioning. For example, a client who comes to therapy and appears disheveled, has difficulty expressing thoughts, and has not been to work in the last three days due to delusions is more than likely at a “1” or a “2” on this scale. A client who has learned coping skills for anxiety, who has implemented these successfully for the past six weeks, and who is now able to attend social functions and engage in healthy relationships with members of his or her support system is probably at an “8,” or a “9”. A client who is at the lower end of the scale may need more intensive or even in-patient treatment. A client who has moved up the scale during the course of therapy to a “9” or a “10” is more than likely at a point where therapy can be reduced or, if appropriate, concluded. Recognizing the level of care a client needs is important in the overall evaluation, and this scale provides not only a quantitative designation of the client’s current level of functioning but also an assessment of the client’s current level of therapeutic needs.
The last part of the evaluation section refers to the DSM-5/ICD-10 diagnoses. Diagnoses for clients may change over the course of counseling as counselors gain new information about the person they are seeing in therapy. If a diagnosis does change, then the counselor may need to modify the treatment plan and counseling goals.
Thinking back to the case study of Samantha (see earlier blog post from November 30, 2015 at https://drrhondasutton.wordpress.com/2015/11/30/the-s-in-the-steps-to-taking-progress-notes-the-subject/), it will be important to see how engaged she is in therapy or if she remains stuck in her patterns of behavior. As her counselor, you will want to see if she is willing to set goals and, if so, does she work towards them? Also, the “E” part of your notes for Samantha will show how well she is functioning (more than likely she was at a “4” or “5” early on in therapy), and following documentation in this section will show if her level of functioning improves, stays the same, or declines. If Samantha’s functioning does improve, it means therapy is working. If it does not, then counseling may need to take on a different approach or incorporate different therapeutic interventions. Also, her diagnosis will need to be more carefully assessed in terms of her anxiety and depression. For example, are her symptoms due to more of what is happening at this time in her life (recent move, husband traveling a lot, sons getting older and needing a different form of discipline)? If this is the case, the symptoms may be more closely aligned with an adjustment disorder. If the depression and anxiety persist, despite attempts she makes to improve different areas of her life, then the diagnosis or diagnoses may need to change to reflect the persistence or seriousness of her symptoms, thoughts and behaviors.
The “E” portion of the STEPnotes provides guidance for counselors in terms of how the therapy is going and how well the client is functioning. The “evaluation” part also is the place to indicate if there is suicidal or homicidal intent or other forms of thoughts or behaviors that indicate a need for a different level of mental health care. This is an important part of the progress note in that it reflects how well the current level of care, the counseling approach, and the goals are helping the client.
More information about the “Evaluation” portion of the STEPnote is available in “The Counselor’s STEPs for Progress Notes: A Guide to Clinical Language and Documentation available on Amazon at: http://www.amazon.com/Counselors-STEPs-Progress-Notes-Documentation/dp/1514643588/. The STEPnotes downloadable form, which can be stored on your computer or the PDF can be uploaded into your EHR, provides options for the evaluation of client’s progress as the well as “Assessment of Client’s Functioning Scale”; this individual counseling note form can be found online at: https://www.stepnotesinc.com/Store. Next post will focus on “P” part of the STEPs; stay tuned!