FAQ: How Do I Document the Counseling Session?

You must use your counseling skills and clinical judgment to determine the level of risk (minimal, moderate or high) for each question the adolescent has identified as a risk for themselves. This would be identified as any question with the box on the right checked.

The “Office Use Only” box on the far right is for you to document on each risk that was identified by the adolescent. If you are reviewing a risk assessment with risks identified you must have documentation that you addressed it with the adolescent. Examples of this documentation could include:

  • –  “counseled, minimal risk”
  • –  “determined not at risk”
  • –  “risk reduction plan developed ~ see notes”
  • –  “past behavior, not current risk”

The “For Office Use Only” on the bottom of the form is for you to evaluate the risk behaviors and your follow up:

  • –  No current risk ~ This will automatically populate on the RAAPS if the youth reported they were not engaging in any risk behaviors.
  • –  At risk counseled ~ This will automatically populate on the RAAPS if the youth identified any risk behaviors. It is assumed that if behaviors were identified the youth was counseled
  • –  Needs follow up ~ It was determined through your counseling that the youth needs follow up on a risk behavior. You should be able to look at the notes in the “Office Use Only” boxes on the far right to determine what behavior this is referring to. Examples of this note could be “high risk, referred to…” Or “discussed, will monitor weekly”.
  • –  Referred to ~ if you referred the youth to someone else in your office or an outside agency for follow up on a risk behavior, you would record here.

If the counselor is documenting in the RAAPS database, choose “save and close” to store the documentation. The RAAPS can be printed with and without provider documentation.

Click here to learn more about RAAPS.

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