Three Authors, One Client: A Qualitative Description of Marriage and Family Therapy Initial Case Documentation

Abstract

During the client screening and initial session process at a marriage and family therapy training clinic, three types of forms are completed: a Telephone Information Form (TIF), completed by an intake coordinator; a Client Information Form (CIF), completed by the client; and a first session Progress Note (PN), completed by the therapist. The researchers examined documents from closed client files of cases seen by masters students at a university-based brief therapy training clinic. Qualitative descriptive analysis was used to explore the level of consistency in the depiction of clients' reasons for coming to therapy within and across cases on the three forms. Findings suggest that there was a high level of consistency between and amongst cases on two of the three forms. Implications for clinical training, practice, supervision, and research are explored.

A review of quality assurance methods to assist professional record keeping: Implications for providers of interpersonal violence treatment

“…Intake forms are used to document demographic history and current concerns, and typically include contact information, identifying characteristics, relevant background information (e.g., treatment history, previous diagnoses, medical information, family history), payment information, and reasons for seeking treatment (Heller, Gilliam, Chenail, & Hall, 2010). This information permits providers to confirm diagnoses and determine if services are within their scope of specialization.…”

Utilizing a Continuing Education Workshop to Increase Knowledge of Documentation Among Hospital Psychosocial Staff

“…Retrospective studies have examined consistency in agency documentation. For example, Heller, Gilliam, Chenail, and Hall (2010) examined closed records of a universitybased brief therapy clinic to assess the level of consistency in documentation forms completed by the client, the intake coordinator, and the master's-level counseling student. That study utilized a small sample of 20 closed records and found high levels of consistency in the recording among all three individuals providing information on presenting problems and other questions on the form.…”