Effective initial assessment documentation enhances client conceptualization and treatment planning, and also sets the foundation for an effective collaborative care environment. Rula aims to format note templates in a way that encourages clear documentation of all elements that should be included in notes that meet industry and regulatory requirements. This article outlines best practices for crafting a high quality initial assessment. For best practices for an initial assessment, we recommend this article.
Examples with Rationale and Best Practice Recommendations
Measurement-Informed Care (MIC)
What to Document:
- Select “Yes” to indicate that you reviewed the most recent MIC data.
- Make a selection(s) under “Based on the clinical measures” to indicate how you used the MIC data to inform assessment and treatment planning.
- For any case involving imminent danger to self/others, a C-SSRS score 2> , and/or PHQ-9 score above 19, a safety plan is required to be present in the chart and the client should be offered crisis resources, like the Rula crisis hotline.
Rationale: Clinical assessments provide objective data to track symptoms over time, ensuring treatment effectiveness and improving clinical decision-making. They also support value-based care models.
History of Presenting Illness
Presenting Problem/Chief Complaint:
What to Document: The client's primary reason for seeking therapy, including a quote from the client. This section focuses on the client’s current symptoms, concerns, or challenges, including any relevant contextual information.
Rationale: This information helps establish a focus for treatment and guides the development of a treatment plan.
Example: Client reports experiencing intrusive memories, nightmares, and heightened anxiety following a car accident three months ago. They describe avoiding driving and feeling on edge daily, which has significantly impacted their ability to work and maintain relationships. Per client, “I feel like my life is on hold after the accident. I can’t do anything because I’m a mess.”
Current Symptoms:
What to Document: Symptoms that the client is currently or has recently experienced in the last few weeks.
Rationale: Documentation of current symptoms is helpful in establishing a diagnosis and to justify the ongoing need for care by providing data about the medical necessity of care.
Example: “Anxiety attacks, difficulty concentrating, emotional numbness, feeling down/depressed/hopeless, feeling nervous/anxious/on edge, flashbacks related to a traumatic event, hypervigilance, impulsiveness, Inability to carry out daily activities or handle daily problems and stress, racing thoughts, Trouble falling or staying asleep, uncontrollable worry”
Areas of functional impairment/ How are symptoms specifically impacting clients functioning in this area?:
What to Document: How each symptom is resulting in difficulty fulfilling roles in key life domains or a negative quality of life for the client.
Rationale: Documentation of functional impairment is vital to prove a case of the medical necessity of care. If one is finding there is little/ no impairment, this may be a sign that a diagnosis is not present, and that ongoing outpatient therapy is not indicated.
Example: “Social/relational, activities of daily living ”- “The client is experiencing intrusion, avoidance, and hyperarousal symptoms, all of which are causing significant impairment in their occupational functioning and personal relationships. The client reports that she recently lost her job, is unable to groom herself effectively or keep her home clean, and broke up with her partner due to increased fighting since the car accident.”
History of mental health treatment/substance use treatment:
What to Document: The client’s history of mental health/substance use treatment across their lifespan, ranging from inpatient to outpatient therapy, as well as any medications. It is recommended to include context about why these treatment episodes began and names of previous providers/treating facilities, if possible.
Rationale: Documentation of the client’s history of care can lend to case conceptualization, including a better understanding of the complexity of the issues at play and mutuable/non-mutuable risk factors.
Example:
- Client was admitted into an inpatient psychiatric unit at X Hospital at age 17 after experiencing suicidal thoughts, intent, and an expressed plan post-sexual assault. Client was admitted for two weeks and then discharged, but chose to not follow up with aftercare recommendations, which was to start weekly individual DBT therapy and establish psychiatric care. Client reported that she did not follow up with aftercare recommendations because she “didn’t feel like [she] needed it.”
- Client has also seen two therapists at Rula for a few sessions, but reported discontinuing care due to them feeling like they were not a good fit for her needs.
- Client is currently taking Wellbutrin for the last 3 months (150mg/once a day) as prescribed by Dr. Fake, who is at Faketree Clinic (323-000-0000).
Family history of mental health treatment/substance use treatment:
What to Document: Any relevant family history that could indicate a genetic component related to mental health or experiences that could have impacted the client’s development in childhood.
Rationale: Documentation of the client’s history of care can lend to case conceptualization related to heritable factors and developmental impacts.
Example: “Client reports that her biological mother used alcohol while she was pregnant with client. Client reports that her mother was diagnosed with depression as a teenager and it was largely untreated. Client has never met her biological father, but reports that her mother indicated that “bipolar, anxiety, and depression runs in his family”.
Psychosocial
Social concerns (educational, employment, legal, financial):
What to Document: Any potential concerns in these content areas where the client could be underresourced.
Rationale: Identifying psychosocial barriers and addressing them with resources can positively impact client outcomes.
Example: “Client reported that she is currently unemployed. Client has a bachelor’s degree in computer science, but reported that the job market is “rough” in tech. The client reported that one of her primary concerns is not being able to pay rent next month.”
Interpersonal/ family information/history:
What to Document: The client’s understanding of their social network, including friends, family, and community support.
Rationale: Understanding a client’s social resources and encouraging them to increase social capital when clinically indicated can improve client outcomes.
Example: “Client reported that she is a ‘loner’. The client's best friend lives in Malibu and they chat regularly, but the client otherwise connects with people online via videogames, social media, and chat forums. Client maintains minimal contact with her mother due to long-term strain in that relationship, and has no contact with her bio father or extended family. The client reported that she enjoyed some of her relationships with her co-workers at her old job, but feels like she cannot continue these relationships as friendships due to her firing.”
Current living situation:
What to Document: Details about the client’s living situation, including cohabitants. It is also recommended to document any relevant safety concerns in the home.
Rationale: Understanding the client’s home life can lead to a more tailored treatment plan. It is also vitally important to assess for the presence of any means that could cause harm to the client and/or community, like abuse, weapons, unsafe living situations, and so on.
Example: “Client lives in an apartment by herself. Client reports that she owns a gun for self-protection as a single woman, and keeps it locked in a gun safe.”
Cultural Considerations:
What to Document: Cultural considerations for treatment could include any of the following. None or N/A is an unacceptable response to this section. Data included in this section should speak to how the client’s lived experience and identities may inform how they may experience mental health treatment and how this may affect their progress in treatment.
- Ethnicity, nationality, language(s) spoken, and preferred language for communication.
- Religious or spiritual beliefs, practices, and their role in daily life.
- Gender identity, sexual orientation, and how they intersect with cultural identity.
- Role of family, community, or cultural groups in decision-making and support.
- Expectations and norms, understanding, and/or stigma regarding mental health within the client's culture.
- Language barriers, financial constraints, or mistrust of medical systems.
- Experiences of discrimination or marginalization.
- Cultural strengths such as resilience, spirituality, or strong community ties.
Rationale: Recognizing and respecting cultural factors helps build trust and rapport, and works to ensure that therapy is culturally responsive and tailored to the client’s intersectional needs.
Example: “Client identifies as a Black, bisexual woman in tech, and indicates that she often feels marginalized and that she ‘doesn’t belong anywhere.’ Client views mental health challenges as a sign of weakness, reflecting cultural stigma, and prefers to remain hyperindependent. Client expresses hesitancy about therapy due to cultural beliefs about mental health.”
Trauma history:
What to Document: If there is a trauma history, brief details about the events that have impacted the client.
Rationale: Having an understanding of the client’s trauma history can inform diagnosis and treatment planning.
Example: “Client reports a sexual assault by a male friend at age 17, resulting in her psychiatric hospitalization. The client also wonders if her recent car accident could be considered traumatic.”
Client Strengths:
What to Document: Positive qualities held by the client that promote resilience, self-reported by the client (ideally quotes from the client) and observed by the therapist.
Rationale: The client’s strengths serve as the bedrock of resiliency and proof of previous coping.
Example: Client reports that she is “smart and funny”. Additionally, this LCSW observed that this client is resourceful, reflective/insightful, and appears to be motivated to change.
Substance use
What to Document:
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For both current and historical substance use:
- Types of substances used (e.g., alcohol, cannabis, prescription medications, illicit drugs) and methods of use
- Frequency of use, duration of use, patterns related to use, including periods of abstinence or relapse
- Quantity (e.g. 1 gram a day, 4 White Claws/week)
- Age of onsent
- Impact on physical, mental, social, functioning
- Risk of withdrawal (e.g., seizures, DTs for alcohol), overdose history
- Risk behaviors (e.g., sharing needles, DUI)..
- Current Use: Recent patterns (e.g., last use, triggers, circumstances), dependence or tolerance indicators (e.g., increased quantities needed, withdrawal symptoms), attempts to quit/reduce use
Rationale: Substance use often affects mental health, so understanding its role helps in diagnosis and treatment. Identifying risky behaviors can allow therapist and client to collaborate and address them, to include safety planning, referral to specialized care, or a higher level of care.
Example:
- Historical use: “The client reports a history of using alcohol, cannabis, and cocaine. First use of alcohol at age 16, with occasional binge drinking through college and after her assault. Began using cannabis at age 16, currently using 2-3 times weekly. Cocaine use started at age 19, with periods of heavy use during stressful events in college. Last use of cocaine was three months ago. The client denies any issues with cutting back/quitting use or increased tolerance, no history of overdose/withdrawal.Plans to drive after drinking have been reported occasionally.
- Current Use: The client currently drinks alcohol 3-4 times per week, consuming 4-5 drinks per occasion. Cannabis use remains at 2-3 times weekly, primarily in the evenings to "relax and sleep." She feels that feel cannabis helps with anxiety but acknowledges a decrease in motivation and productivity, which resulted in arguments with her ex-partner.”
Clinical Summary
What to document: Key details from the rest of the initial assessment, such as symptoms that support diagnosis and functional impairments, relevant biopsychosocial factors, and the client’s presentation in the intake appointment. This summary should demonstrate how the client’s symptoms meet DSM criteria for diagnosis, and may also briefly discuss the plan of care moving forward. This section should not be copy/pasted from the “History of Presenting Illness" section.
Rationale: A thorough summary is vital in establishing medical necessity of care.
Example:
Client is a 29 y.o. Black, bisexual, cisgender female that works in tech seeking mental health treatment following a car accident three months ago. She reports experiencing significant distress including intrusive memories, nightmares, and heightened anxiety. Due to these symptoms she’s unable to drive, focus at work, and describes feeling "on edge" constantly. The client states, "I feel like my life is on hold after the accident. I can’t do anything because I’m a mess." The client’s PHQ9 (21) and GAD7 (17) scores indicate severe anxiety and depression symptoms. In addition to the recent trauma, this client has a history of trauma in both childhood and adulthood, which has caused periods of excessive substance use. Historically, she has had difficulty remaining engaged in mental health treatment, but appears to be motivated for treatment at this time.
Outpatient therapy treatment is necessary to address the client’s PTSD and improve her functioning via DBT and EMDR. Treatment will also include continued evaluation of client’s substance use to determine if a substance use disorder is warranted.
Diagnosis
Diagnosis:
What to Document: Clinically appropriate diagnosis/diagnoses
Rationale: A diagnosis helps determine the best treatment options for the client and informs the insurance partner of the specific condition being treated with therapy. The initial assessment documentation should support full DSM-V diagnostic criteria for all diagnoses assigned at intake. At least one F-code is required to bill for services. For best practices regarding diagnoses, please check out this article.
Session Time
What to document: You can only bill for time actively spent with the client, not time spent waiting for the client or documenting the session. 90791 can only be used if you have spent more than 16 minutes with the client in session.
Rationale: Documentation of time spent with the client and the associated CPT code needs to be accurate. A pattern of sessions that starts and ends at the :00 or :30 is often flagged by auditors.
Treatment Plan
What to document: Record the client’s goal in their own words (“Client’s Goal”), translate that goal into clinical language (“Clinical Goal”), and measurable actions the client will take to work toward their goal (“Short-Term Objective(s)”).
Best practices:
- Utilize the SMART (Specific, Measurable, Achievable, Realistic, Time-Bound) framework to develop treatment goals.
- The Short-Term Objective section of the Rula Treatment Plan is where you should specify the measurable steps, behavior shifts, and/or skills that the client needs to make progress toward their goal.
- Ensure Relate treatment goals are related back to the DSM-5 criteria for the client’s assigned diagnosis(es).
- Consider up to 3 treatment goals. More than 3 can feel overwhelming to a client and potentially dilute the efficacy of treatment.
- In order to meet compliance standards, update the treatment plan at least every 3 months.
Example:
- The client reports their goal is to: “not be so keyed up all the time”
- The client’s clinical goal is: Symptom reduction
- Short-Term Objective: The client will practice a grounding technique, such as deep breathing or the 5-4-3-2-1 method, at least three times per week for six weeks to manage anxiety symptoms triggered by flashbacks or intrusive thoughts, tracking their use in a journal to evaluate progress in therapy.
To learn more about treatment planning, please visit this article! More examples can be found here, as well as a resource that discussed how to use MIC to inform treatment planning.
Want to see how all of this fits together to create an effective, compliant note? Rula offers a robust Sample Documentation Library, including examples of many different initial assessment notes for adult, child, couples, and families!