Documentation Training: Part I INSTRUCTIONS

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Documentation Training Part IINSTRUCTIONS

• When you click on underlined text, you will see
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Documentation Training Part One

• How to communicate in writing what you and the
  client are doing in treatment

Presented by Charleston-Dorchester MHC-
Quality Improvement Department
Revised 8/06
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Making the most of this presentation

• There are two parts to this training and all
  clinical staff are required to complete both
  parts.
• It is very important that you write down any
  questions as you review these slides, whether
  they are general or specific to your area and
  contact your Supervisor or us via e-mail
  quality improvement or phone [phone].
• Finally, please feel free to print out the slides
  (recommend 3 slides per page with black/white
  option) know that you can always come back and
  review them at any time.

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Agenda Part I

• Introduction to Quality Improvement
• 2005 Treatment Service Standards An Overview
• Consents
• Approved Abbreviations
• Plan of Care (POC)
• (aka Individual Treatment Plan ITP)

.
To the left are the items covered in this
presentation. You will need to review both Parts
I and II to receive credit.
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What is Quality Improvement?

• Quality Improvement is what the Charleston
  Dorchester Mental Health Center continuously
  strives for
• Improving access to our services by people in the
  community
• Providing best practice services to our
  clients
• Providing professional development opportunities
  for our staff
• Increasing the licensure and certification of our
  staff
• Continuously monitoring the effectiveness and
  efficiency of our treatment services and the
  satisfaction of our clients

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Quality Improvement Department

• SUSAN MONOGAN
• M.S ,ED.S.,L.P.C.,N.C.C., L.P.C.S. 727-2000 X
  117
• TOM ELLIOTT
• M.S PSYCHOLOGY 727-2000 X 124
• JENNIFER PARKS
• M.Ed., L.P.C., N.C.C.,L.P.C.S. 727-2000 X 115
• JANICE RUDICH
• B.A. PSYCHOLOGY727-2000 X 146
• Initially, the Quality Assurance Dept. was
  established to provide a system of monitoring
  that assures both internal and external agencies
  that the Center is meeting SCDMH Standards
  including Corporate Compliance and CARF,
  Medicaid/Medicare Standards and HIPAA
  Regulations.
• Although this is still a large part of our job (
  and now include Corporate Compliance) the
  Department has evolved over time and its name has
  changed to Quality Improvement to reflect the
  more proactive aspects of the department and of
  their work, e.g. trainings (such as this one
  youre doing), consulting with clinical teams to
  improve quality of service delivery, and
  utilization reviews to determine center-wide
  patterns.

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Our Services and Medicaid

• The services you provide to clients (i.e. STAD,
  Individual Therapy, TCM) are based on standards
  developed by Medicaid.
• An Overview of the Medicaid (DHHS) Treatment
  Service Standards may be found on www.cdcmhc.org
  , under Staff Only, Quality Improvement, QI
  Miscellaneous.
• The TX. Service Codes, Descriptions, Units, and
  Rates are also available on the CDCMHC web-site.
• These are new treatment standards and became
  effective February 2005.

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Medicaid Standards

• The Overview of the 2005 Medicaid Treatment
  Services
• includes information related to
• Treatment Service Description Codes
• Service Abbreviations
• Whether or not a 2 week staffing is required
• Staffing Ratio
• Lowest Staff Credentials to provide the service
• POC Requirements Whether or not the service
  must be listed on the POC and if so what type of
  frequency is required
• Whether or not a MHP Co-signature is required on
  documentation
• Treatment Tx Services that Cannot be provided
  on the same day

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Consents

• Be sure to have the legal guardian sign if
  patient is under the age of 16.
• Persons 16 years of age and older should sign the
  consent for treatment and all corresponding
  documentation
• If other people are participating in treatment,
  they need to sign the consent and the
  relationship should also be identified on the
  consent form.
• The signer of the consent should also be the
  signer of the POC.

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Abbreviations

• Part of documentation is saving time through
  abbreviations, but you must use abbreviations
  that are approved.
• An Abbreviation List is located on our website
  and in our QI Manual
• Should you have recommendations for
  abbreviations, please communicate them to the QI
  Department.

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POC Plan of Care(aka ITP Individual
Treatment Plan)

• The Plan of Care (POC) is a working, living
  document. As the client progresses in treatment
  towards recovery, the goals, objectives,
  interventions and services may change. These
  changes need to be reflected in the plan of care

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Using SNAPS to develop individualized goals for a
POC

• Strengths
• What do you enjoy doing? What interests you?
• What kinds of things do you do well?
• What natural talents do you have?
• What aspects of yourself help you keep your
  mental and physical health?
• Sometimes you may need to provide examples
  belief in God, church members are supportive,
  love to read, good supportive familyetc.
• You may also include clinicians perception of
  the clients strengths
• Needs
• Are there things you would like to know or learn?
• Are there areas in your life that you need other
  people to help you with or do for you?

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Using SNAPS to develop individualized goals for a
POC

• Needs
• Provide examples if needed money management,
  housing, employment
• You may also include clinicians perception of
  needs
• Abilities
• What skills do you have?
• What are you good at doing?
• Provide examples if needed electronic games,
  drawing, mechanical
• You may also include the clinicians perception
  of the clients abilities
• Preferences
• Do you have any preferences regarding your
  treatment, such as a male or female counselor?
  Having your appointments in the morning or early
  evening?

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GOALS

• The goals for the client help to provide a
  general direction of treatment.
• Goals need to be in the clients own words. If
  not possible, these should be stated by a family
  member or the therapist
• When the client does not state his/her own goals,
  this should be indicated on the Plan of Care, in
  parentheses under the goal
• E.g. (mothers goal) or ( therapists goal)
• Later, when the client is able to actively
  participate in goal development the goals should
  reflect the clients own words
• Examples of goals
• I want to stay out of the hospital
• I dont want to be sad anymore
• I want him to stay in school ( Mothers goal)
• I want to live alone

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Goals- continued

• Here are some questions you can ask that may help
  you with getting appropriate goals
• 1. What would you like to get from coming
  here?
• 2. How do you want me to help you?
• 3. What would you be doing if you werent
  having these symptoms/feeling this
  way/acting this way?
• 4. How would your life be different if you felt
  better?
• 5. What do you want to change in your life?

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OBJECTIVES

• Objectives are the behavioral steps that the
  client needs to take to achieve their goal(s)
• They need to be written so the client knows what
  s/he is working on
• Objectives must be able to be measured so the
  client and you will know when they have been
  achieved
• Objectives need to be realistic, i.e. based on
  what the client thinks they can do, not on what
  the clinician thinks the client should do so the
  client is able to succeed!

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Objectives continued

• Examples of Objectives
• 1. Alisha will receive two or less referrals to
  the principals office per week as reported by
  her teacher ( note the baseline 5 referrals a
  week)
• 2. Antonio will report two or less panic attacks
  per week (note his baseline 4 or more per week)
  as reported by client and/or his mother.
• 3. Sara will decrease outbursts from 4 times
  daily to 1-2 times daily as reported by client
  and teacher.
• 4. Michael will learn to create a monthly budget
  and spend within budget 4/6 months as reported
  by client and guardian.
• 5. Ahmed will learn to fill his pill minder and
  take the meds as prescribed as evidenced by spot
  checks of pill minder by counselor and lab
  results.

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INTERVENTIONS

• Interventions are the methods or specific
  treatment approaches to be used by the clinician
  to help the client meet their objectives
• Sometimes the treatment service is the
  intervention, e.g.
• Clinician will help Jerome work through his
  fathers death via individual counseling, 2x
  weekly for 60 days.
• Other times, you need to cite specific
  interventions that will help client accomplish
  objective, e.g.
• - Clinician will teach La Tasha relaxation
  techniques to assist her with trauma issues.
• Clinician will use DBT techniques to help client
  change her self-destructive behaviors
• Clinician will employ role playing to help
  change Samuels aggressive behaviors..
• Remember that the interventions cannot
  be experimental therapies. They must be
  recognized by appropriate profession(s)

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POC Page 1

• Completed annually.
• Remember you need all 3 signatures on this page.
  You and the client must sign the POC. If the
  client refuses to sign please indicate so on the
  POC. Paybacks occur if the MD does not sign and
  date.
• Number your goals, (i.e. 1,2,3 etc.) as well as
  your objectives /interventions (i.e. 1A, 1B, 2A
  )
• In the space Type of staff list the lowest
  credentialed staff to provide the service. This
  can be found on the Overview of the 2005 Medicaid
  Treatment Services

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POC Page 1- continued

• The initial POC must be signed by the MD within
  90 days of admission and is effective for 1 year
  from the date of admission .
• The POC can be written up to 30 days prior to the
  renewal (expiration) date with the MD documenting
  effective for and then stating the actual
  renewal date
• e.g. John Smith MD 1-1-06
• (effective for
  1-12-06)

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POC Page 1- continued

• All renewal dates should correspond with the Date
  of Admission
• If for some reason the renewal date does not
  correspond with the Date of Admission
• 1. the POC is valid for one year from the MDs
  signature
• 2. We should ensure that the POC is renewed the
  following year on the anniversary of the date of
  admission
• E.g. according to the MD signature the POC
  expires 11/01/06 and the Date of admission is
  10-01-06.Renew the POC on 10-01-06 so that from
  then on it renews on the Date of Admission

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POC Page 2

• Please ensure all spaces on the POC are complete,
  indicating None at this time or N/A where
  appropriate. Do not use NA or None for any of
  the SNAPS-please!
• Goals for discharge are required to be on all
  POCs.
• All clinicians providing services to the client
  need to be familiar with the POC to write proper
  documentation.
• Certain services require a Medical Necessity
  Statement in addition to being put on the POC
  e.g. each type of WRAPS service

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POC Addendum

• Whenever you initiate this page you must obtain
  all three signatures located on the bottom
  (client, MHP,MD)
• This page expires at the same time as the POC
• At the time of the POC renewal this page also
  requires all three signatures (client,MHP,MD)
  
• Any time you add a service or change a frequency
  the MD must initial and date these
  additions/changes.

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POC Addendum

• In order to justify continued treatment, most
  clients and their counselors might need to change
  goals or objectives, services, and/or frequencies
  until all treatment needs are met
• This addendum page permits you to add more goals,
  objectives and/or services
• Addendum pages may be added as needed. Remember
  to keep the goal numbers sequential .(e.g.
  1.,2.,3.,)

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POC Progress Summary (90 day 180 day)

• The Progress Summary is required every 90 days
  and should coincide with the Date of Admission.
• It is important to rate the measurable objectives
  of your goals appropriately. If the client has
  mastered an objective/goal, it should not be
  included on the next POC.

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POC Progress Summary(270 day 360 day)

• NEW POC TRAINING(8/06) NOW AVAILABLE ON WEBSITE
  UNDER QUALITY IMPROVEMENT/TRAINING

• The 360 day Progress Summary also includes a
  Annual CARF requirement that you review with the
  client their Rights and Responsibilities and
  document that in the Progress Summary. It is also
  the time to update the Initial Clinical
  Assessment.
• Adults must document a GAF score at each Progress
  Summary
• The most recent version of the ITP ( now called
  POC) is effective 07/06.
• The newest ICA just came out 7/31/06.

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Conclusion

• Click here to confirm completion of this training
  Email Sherri Dangerfield a blank e-mail will
  be generated for you to complete. Be sure the
  email contains your full name, staff ID, and
  office.
• Contact the QI Department any questions about
  this presentation.
• Email Quality Improvement within DMH and
  using Groupwise
• Email qiu3b_at_scdmh.org outside of DMH

Click here to end