The documentation within your progress note should clearly explain why HLOC was recommended, how the recommendation was discussed with the client, and what plan was established for follow-up and continuity of care.
Simply documenting that "a HLOC was recommended" is not sufficient. The medical record should demonstrate the provider's clinical assessment, reasoning, the client's response, and the follow-up plan.
What should my documentation include?
- Relevant assessment findings and changes in clinical presentation
- Clinical concerns supporting the recommendation
- The level of care recommended
- The clinical rationale for the specific level of care
- How the recommendation was discussed with the client
- Education or information provided to the client
- The client's response, preferences, questions, or concerns
- Barriers to accessing the recommended level of care
- Resources, referrals, or options discussed or provided
- Alternatives considered and the clinical rationale for those alternatives
- Safety planning, crisis planning, or other interim interventions
- Coordination with other providers or supports, as applicable
- Follow-up plans
- Any subsequent changes to the recommendation, treatment plan, or client's status
Example of what strong documentation should demonstrate
Your documentation should allow another clinician reviewing the record to understand:
What changed → What did you assess → Why did you recommend HLOC → How did the client respond → What barriers or alternatives were considered → What is the plan now?
This creates a clearer record of the clinical decision-making process and the client's ongoing care plan.