Members are usually surrounded by people who have or could have a significant role in their recovery. We can help members accomplish their goals by providing education and training to these individuals and involving them in the member's treatment. These are called Collateral services. They can be done with or without the member present.
Although significant support persons are usually aware of a member's diagnosis, always be mindful of confidentiality. Also, for services to be billable, the member must be the primary beneficiary -- in other words, the service must be designed to help the support person help the member, not deal with their own issues. Offering suggestions on how a family member can manage the stress of caregiving, for example, would not be billable as collateral.
G: Jorge is a 29 y/o single Hispanic male who is back at his R&B now after being hospitalized for DTO. His symptoms are currently under control but when his A/H and paranoia get worse, he becomes aggressive and makes threats. I met with his R&B manager, Marcela, to offer suggestions on how she can help Jorge reduce these behaviors.
I: Explained to Marcela that when volume levels in her home are high or several people are talking at once, Jorge's voices sometimes get louder and more distracting. Suggested she try speaking with him outside, using a calm tone of voice, in a quieter place with fewer distractions. Also recommended she help Jorge establish a set bedtime-uptime schedule that includes taking his meds at a specific time each day.
R: Marcela was open to my suggestions and agreed to try them. Jorge was not present for this service.
P: Plan is to follow-up with Marcela next week to see if she has been able to implement these suggestions and if so, how Jorge responded to them.
TT: Driving alone between TAO and Jorge's R&B.
In situations like this, it's fine to use "R" to describe the support person's response.
G: Elizabeth is a 33 y/o single Caucasian female who is diagnosed with bipolar disorder. She has a long and recent history of stopping her medications or trying to adjust them so that she experiences the highs of her illness but not the lows. This behavior results in repeated manic episodes that often require hospitalization to resolve. I met with Elizabeth's R&B manager, Rosa, to educate her on Elizabeth's illness and offer suggestions on what she can do to help.
I: Educated Rosa on the symptoms of bipolar disorder. Explained that in the early stages of a manic episode, Elizabeth might seem happier and more helpful. She might do a better job on her chores or volunteer to do additional work around the house. But if she starts talking more than usual, jumps from topic to topic, and/or seems to be awake at all hours of the night, it may be an indication she needs help. Advised Rosa that if she observes any of these symptoms, she should call me or a member of Elizabeth's treatment team and let us know.
R: Rosa was open to learning about Elizabeth's illness and agreed to contact me if observed any of the behaviors I was describing.
P: Will continue to support Elizabeth by providing education to significant support persons in her life.
TT: Driving alone between TAO and Elizabeth's R&B.
Note that in both examples, the writer has just explained the problem in "G" rather than trying to describe it using symptom-behavior-impairment. This is okay, as long as "G" connects the intervention to the member's mental illness and reflects information that can be found in their treatment plan.