Documentation Training: Part I INSTRUCTIONS

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Documentation Training Part IINSTRUCTIONS

• When you click on underlined text, you will see
  examples of documents. If prompted to log-in,
  please enter staff for the user ID and scdmh
  for the password.
• After viewing a link, click back on the upper
  left hand part of your screen to return to this
  presentation.
• If a new screen opened, the back button may be
  unavailable to you. In this case, close that
  screen to return to the presentation
• The icons below include a description of what
  each icon represents. Click one of the icons
  appearing in the lower right corner of the screen
  to begin this training. . .

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Documentation Training Part One

• How to make it through the mountains of clinical
  documentation . . .

Presented by The Quality Improvement Department
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Making the most of this presentation

• Documentation Training has always been done in
  person. However, due to staffing and demands on
  the QI Department, we started this online version
  in the fall of 2003 to replace the in-person
  training.
• 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 your review these slides, whether
  they are general or specific to your area and
  contact QI to assist you.
• Also, please complete an evaluation at the end.
  These are anonymous, so your feedback regarding
  what helped or what you needed more information
  on is beneficial to us as we continue to improve
  our training.
• This presentation will refer to your QI Manual.
  It may be helpful to have it nearby as you review
  the slides. If you do not have a QI Manual, you
  may pick one up at Port City Center.
• Finally, please feel free to print out the slides
  and know that you can always come back and review
  them at any time.

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Agenda of Part I
.

• Introduction to QI
• 1994 Standards An Overview
• Consents
• Approved Abbreviations
• 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?

• The next slide provides an organizational outline
  of the QI Department which consists of the QI and
  Corporate Compliance Director and three auditors.
• The QI team is responsible for various types of
  reviews such as quarterly audits, utilization
  reviews, corporate compliance reviews and at
  times, consultative reviews. (These are
  explained in your QI Manual).
• The QI Department was established to provide a
  system of monitoring that provides assurance of
  meeting SCDMH Standards, including Corporate
  Compliance and CARF, and Medicaid/Medicare
  Standards and HIPAA Regulations to achieve the
  highest degree of clinical excellence.
• The QI Department audits in compliance with local
  standards (CDCMHC, CARF, and DMH) , state
  requirements (payor sources which include
  insurance companies), and federal guidelines,
  which include Medicaid and Medicare Standards.
  For audits, the QI team uses the QI Audit Tool.
  Errors cited may include non payback and payback
  type errors. The QI Department strives to audit
  a minimum of 10 of the Centers caseload each
  year.

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Introduction

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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 in your QI Manual
  and the CDCMHC web-site. This will explain the
  key points of the standards.
• Please note the names of services changes October
  of 2003, but the overall content has remained the
  same. New standards are expected in the summer
  of 2004.

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Medicaid Standards

• Overview includes the following items
• Treatment Service
• Target Population
• Treatment Modes
• Staffing Ratio
• Goal of Treatment
• Staff Credentials to be Privileged as Providers
• Bill Unit Maximum Billable Units
• ITP Requirements Listed On ITP Type of
  Frequency
• Treatment Tx Services That Cannot Be Provided
  Same Day
• Special Documentation Features

A complete chart is found under Service
Standards in your manual
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Consents
See the Confidentiality section of your Manual
for more information

• 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.
• If persons are participating in treatment, the
  person should sign and the relationship should be
  identified on the consent form.
• The signer of the consent should also be the
  signer of the ITP.

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Abbreviations

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

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ITP Page 1

• Completed annually.
• Certain services require a PMO order in addition
  to being on the ITP please refer to the memos
  on the QI web page for details.
• By June 2004, the MD signature date should
  correspond with the date of admission.
• Without an MD and MHP signature, paybacks will
  occur.
• Goals need to be understandable to the clients
  and based on the strengths, needs, abilities, and
  preferences.
• All clinicians need to be familiar with the ITP
  to write proper documentation.
• PLEASE REFER TO INSTRUCTION GUIDE IN YOUR MANUAL
  FOR DETAILS.

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Using SNAPS to develop individualized goals for
an ITP

• 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 need to provide examples belief in
  God, church members are supportive, love to read,
  good supportive familyetc.
• Which of your good points do you most often
  forget?
• 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?
• Provide examples if needed money management,
  housing, employment
• Abilities
• What skills do you have?
• What are you good at doing?
• Provide examples if needed working with my
  hands, mechanical, electrical, sewing,
• 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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Goal Statements

• Increase level of self-confidence
• Increase self-esteem, sense of independence, and
  activity level
• Learn more constructive expression of feelings
• Maximize functioning and coping skills
• Enable family members to develop understanding of
  the disorder, deal with their own related needs
  and feelings, and learn how to help the affected
  family member.

• Develop social and communication skills
• Improve socialization and peer-group involvement
• Reduce anxiety and depression related to.
• Stabilize mood
• Reduce level of depression

Refer to the ITP section of your Manual for a
more complete listing of goals and objectives
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Creating Measurable Objectives

• List specific things he or she can do to..and
  ways to implement each.
• Initiate ___ social contacts per ______.
• As demonstrated by
• Verbalize situations in which.
• Report reduced frequency of .

• Increase participation in..
• Develop.
• Client will develop a list of.
• Keep a daily written record of.
• Report diminishing or absence of

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ITP Page 2

• Please ensure all spaces on the ITP are complete,
  indicating None at this time where appropriate.
• Goals for discharge are required to be on all
  ITPs.
• Remember to have all signatures on this page.
  Paybacks occur if the clinician and MD do not
  sign and date.
• The team planning/linking conference is due
  sometime during the treatment period. Many find
  it helpful to complete when reviewing a new plan
  with a client, but it is not required at this
  time.

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ITP Page 3

• The Treatment Review is done when closing out the
  ITP, not at the beginning.
• Please review the checklist (found in your
  manual) when completing the review.
• It is important to rate your goals appropriately.
  If the client has mastered a goal, it should not
  be on the next ITP.
• Remember to review client rights and
  responsibilities at this time.
• The most recent version of the ITP was
  distributed 09/03.

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Clinical History and Evaluation Annual Update
Checklist

• ____ 1. LIST OF ALL SERVICES PROVIDED
• ____ 2. SUMMARY OF PROGRESS ON GOALS
• ____ 3. ANY CHANGES IN TREATMENT
• (INCREASED FREQUENCY, ADDITIONAL SERVICES)
• ____ 4. ANY CHANGE IN LEVEL OF CARE
• ____ 5. CLINICAL JUSTIFICATION FOR CONTINUING
  TREATMENT

• ____ 6. ANY HOSPITALIZATIONS
• (MEDICAL OR PSYCHIATRIC REASON FOR
  HOSPITALIZATION)
• ____ 7. HARM TOWARD SELF OR OTHERS
• ____ 8. CHANGE IN EMERGENCY CONTACT NAME/PHONE
  
• ____ 9. CHANGE IN PRIMARY CARE PHYSICIAN
• ____10. CHANGE IN MARITAL STATUS

Refer to the ITP section of your Manual for a
complete list

• This form does not go in the chart.
• Note not all items will apply to your client.

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ITP Page 1A

• This is the additional goal sheet if you run out
  of room when writing your goals.
• Please note this is different from an Addendum
  ITP which is used in Crisis Stabilization.

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Conclusion

• Click here to confirm completion of this training
• Contact the QI Department any questions about
  this presentation.
• Email Quality Improvement within DMH and
  using Groupwise
• Email qiu3b_at_dmh.state.sc.us outside of DMH

Click here to end