Symptoms

The Importance of Documenting Client Symptoms Effectively

Documenting a client’s symptomatic picture is a crucial aspect of providing high-quality care. The forms we use in our field often prompt us to identify the symptoms a client is currently presenting with. It's important to recognize that throughout a client’s treatment episode, symptoms—whether related to withdrawal or other factors—will likely evolve. These symptoms typically shift from physical manifestations to the acuity of mental status as treatment progresses.

When gathering the information needed to justify a continued stay, open-ended questions are essential. These questions minimize the risk of clients underreporting their symptoms by encouraging them to share a narrative rather than offering a simple "yes" or "no" response.

PHP: Capturing Early Symptoms

In the Partial Hospitalization Program (PHP) phase, many clients enter treatment with limited sobriety. Clients who meet the criteria for PHP often present with a range of withdrawal and physical symptoms, such as:

• Gastrointestinal distress

• Poor appetite

• Sleep disturbances

• Restless legs

• Body aches and headaches

• Mild sweats and nausea

• Relapse nightmares (e.g., waking up with the taste of drugs or alcohol in their mouth)

  
  

Effective documentation begins with thoughtful questioning. For example, instead of asking, “Are you experiencing any sleep disturbances?” you could prompt the client with, “Tell me about your sleep patterns.” This open-ended approach encourages clients to provide detailed information, allowing clinicians to assess the impact of symptoms like nightmares or poor sleep on the client’s daily functioning.

The overarching goal of treatment at this stage is to decrease symptoms and increase functioning. As clients progress through treatment, this progress should be carefully documented to ensure their evolving needs are met.

RTC: Monitoring Mental Acuity

During Residential Treatment Center (RTC) stays, physical symptoms of withdrawal typically diminish. At this stage, the focus shifts to the client’s mental status acuity. Clinicians should continue to document symptoms and changes meticulously, as this information is critical for tailoring treatment plans and preparing for eventual discharge.

IOP/OP: Documenting Stabilized Clients

At the Intensive Outpatient (IOP) and Outpatient (OP) levels of care, clients have often stabilized from their physical withdrawal symptoms. However, ongoing documentation is just as important, as it helps justify continued care and identifies areas where clients still need support.

Key symptoms to document at these levels include:

• Cognitive distortions

• Glorification of past substance use

• Irritability or anxiety

• Passive suicidal ideation (SI)

• Physical manifestations of fear or anxiety

• Romanticizing post-discharge moderation in substance use

• Low ADLs (Activities of Daily Living), such as appearing malodorous or disheveled

  
  

Low ADLs are particularly significant, as they reflect the client’s struggle with basic daily responsibilities. Documenting these issues demonstrates the foreseeability of the client being unable to manage tasks like medication adherence or emotional regulation, which are critical for relapse prevention.

Linking Symptoms to the Treatment Plan

The value of symptom documentation lies in its connection to the treatment plan. Each documented symptom should correspond to a specific treatment goal or intervention. For example, consider the following statement:

“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. However, the individual is not yet sufficiently stabilized to be safely and effectively treated at a less restrictive level of care.”

This kind of documentation not only demonstrates progress but also provides a clear rationale for continued care at the current level.

Conclusion

Accurate and detailed symptom documentation is foundational to effective treatment. By using open-ended questions, tracking symptom evolution, and aligning treatment plans with client needs, clinicians can ensure that clients receive the care necessary to progress toward recovery.