Documentation & Treatment Planning builds the skill that makes substance use treatment accountable, coordinated, and reimbursable. Under Chapter 245G, each client has an individual treatment plan, and progress notes record the services delivered. Your documentation is where treatment is recorded, communicated, and proven. This course covers why documentation matters, the documents that frame care (assessment, individual treatment plan, progress notes, treatment plan reviews), the 'golden thread' connecting them, treatment-plan timelines, writing effective notes, objective and non-judgmental language, timeliness, corrections, and confidentiality of records. The throughline: good documentation tells the honest story of treatment — what was needed, what was done, and how the client responded — in a way that supports care, meets 245G standards, and protects everyone.

Learning Objectives

• Explain why documentation matters in SUD treatment
• Describe the assessment, treatment plan, and progress notes
• Apply the 'golden thread' linking need, plan, and service
• Write effective, objective progress notes
• Document in a timely manner and correct errors properly