Documentation Documentation… - PowerPoint Presentation

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DocumentationSlide2

Documentation…

Documentation tells a story

Quality documentation tells a story that everyone can understand

What does your documentation say about you? Slide3

Financial implications

Documentation is a receipt, warranty and guarantee for payments received.

You cannot afford to have bad documentation

An auditor can take money back when services are not appropriately documented. Slide4

Ethical Implications

Documentation outlines your activities with consumers.

Our profession expects documentation.

Your documentation is not written to win a lawsuit, rather to prevent a lawsuit.

Document what you have done to ensure the client’s safety.

Also document why you didn’t use certain lesser restrictive interventions.

It is part of our code of conduct. Slide5

Professional Implications

Other professionals read your documentation.

Your documentation can be subpoenaed for legal purposes.

Caregiver or licensing can reprimand you.

Caregiver or licensing can revoke your ability to work in this field.

It is a professional expectation. Slide6

Documentation Tips

Document to show your thought process and why you did what you did.

Make your documentation obvious.

What you write will be show what you consider as most important.

Use quotes if possible, from everyone.

Write why you didn’t use certain interventions.Slide7

Risk Management Tool

Documentation outlines your activities with the consumer.

Documentation protects the consumer.

Documentation improves the continuity of care for the consumer.

Documentation protects the professional as it communicates your clinical judgment. Quote direct statements when appropriate. Slide8

Liability

With good documentation- liability decreases

Without good documentation- liability increases

Practice standards- quality documentation ensures healthy and quality standardsSlide9

Remember…

Documentation is one of the most important aspects of your work

If it is not documented, it’s very difficult to show what happenedSlide10

Overall Guidelines

The record must be legible and complete.

Do not leave blank spaces

Use professional language-be aware of the fact that outside parties read our charts (licensing, courts, etc.).Slide11

Overall Guidelines (Continued)

Slang terminology should be used only when quoting individuals.

Report the facts. Use quotes when appropriate and useful.

Avoid judgmental/derogatory descriptions

Obtain information regarding support persons- phone numbers, addresses, signature etc. This assists in representing good faith effort. Slide12

Importance of Spelling

Historical Information

Previous Contacts

Crisis Plan

Legal ObligationSlide13

Spelling Activity

http://www.youtube.com/watch?v=9ViaBgG7sMw

Spelling Test-Trainer see your handout provide names before moving to next slideSlide14

Sierra Brazee

Monika Hyde

Kristoffer Laffin

Deputy Boushon

Iris Coakley

Ciera JohnsonSlide15

Emergency Services Assessment

NWC Specific DocumentationSlide16

Demographics

Crisis Plan/Alert

Insurance

Student

Veteran

Race/Ethnicity

County/Billing and Reporting Codes-see handout

Parent/Guardian(not just children)

SupportsSlide17

Logistics

THIS SLIDE IN CONSTRUCTIONSlide18

Mobile

Crisis Worker Name

Credentials

Travel Mileage

Travel Time(minutes)

Assessment Time(minutes)

Documentation Time(minutes)

Total Time(minutes and convert to units)

Units-HandoutSlide19

Telephone

Crisis Worker Name

Credentials

Contact Begin Time(military time)

Contact End Time (military time)

Total Contact Time (minutes)

Documentation Time(minutes)

Total Time(minutes then convert to units)

Units-HandoutSlide20

Assessment

Client’s perception of the situation and desired outcome (include an inquiry about changes in daily activities sleep, appetite, environmental safety):

Are you currently under the influence of alcohol or other substances?

Please describe your alcohol/substance use:

Are you currently receiving any services related to your mental health (i.e. therapy, psychiatrist, county programming)

If Yes- what services/program, where and contact information if available:

Self or collateral reported diagnosis:

Have you ever been admitted to a behavioral health hospital/unit?

Was this voluntary /involuntary, when and where:

Are you currently taking any medications (prescription/over the counter)?

If yes what are they and do you take them as prescribed?

Do you have any current medical issues or concerns?

Have you ever intentionally harmed yourself (i.e. cutting, burning, etc.)?

Legal status and history (i.e. probation, parole, civil commitment, guardianship:

      Does the client have access to firearms, potential hazards or items that are part of an identified plan of self-harm and/or suicide?      

If putting information obtained from another party clearly indicate who is providing this informationSlide21

AODA Factors

What substances has client used today or in their history? And description of use.

Is client currently or soon to be going through detox?

What is a PBT/BAC

Withdrawal Symptoms

Where these observations

Notifications from medical staff

Supports reportsSlide22

Self Harm/Deliberate Self Harm

Superficial

Scratching

Burning

Lacerations

Banging

Descriptions:

What do those mean

Level of medical intervention necessary/received

Use quotes if neededSlide23

Collaboration-Columbia

Columbia-Suicide Severity Rating Scale

Ask Questions 1 &2 address context of responses in the narrative

1. Have you wished you were dead or wished you could go to sleep and not wake up?

2. Have you actually had any thoughts of killing yourself?

If YES to 2, ask questions 3, 4, 5 and 6. If NO to 2, go directly to question 6

Address context of responses in the narrative

3. Have you been thinking about how you might kill yourself?

4. Have you had these thoughts and had some intention of acting on them?

5. Have you started to work out or worked out the details of how to kill yourself?

Do you intend to carry out this plan?

6. Have you ever done anything, started to do anything, or prepared to do anything to end your life?

How long ago did you do any of these?

Are you having thoughts or feelings of wanting to harm or kill someone else

If Yes:

Have you ever done anything or prepared to do anything to harm/kill someone:

     Slide24

Summary of Assessment

Initial Contact Concerns

Who made contact with the Emergency Mental Health Services System

What were the circumstances resulting in contact with Emergency Service and the point of contacts concerns/requests

Officer

Smith of

the

Gatwick Police

Department contacted Northwest Connections concerning

John Doe.

Officer Smith reported

John’s sister Suzie Q contacted

law enforcement tonight after

John and

his girlfriend got into a

verbal

argument and

John texted his sister stating “I hate my life and don’t want to be here any longer”Slide25

Summary of AssessmentSummary of Contact(s)

Outline who you interviewed

Their perception of the situation

The outcome they initially wanted see occur (if known)

Any additional information

you obtained that assisted in your decision making

If

utilizing clinical consultation include that consultation outline in this

section

Quotes related

Remain objective and non-judgmentalSlide26

Documenting-Mental Status Observations

Mental Status Observations

Possible descriptors:

Appearance

posture, clothes, grooming

Behavior

Mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests,

compulsions.Slide27

Documenting

Speech

Possible descriptors:

Talkative, spontaneous, expansive

Fast, slow, normal, pressured.

Loud, soft, monotone, weak, strong.

Slurred, clear, with appropriately placed inflections, hesitant, with good articulation,Slide28

Affect-Observed

Appropriateness to situation, consistency with mood, congruency with thought content.

Fluctuations: Labile, even.

Range: Broad, restricted.

Intensity: Blunted, flat, normal intensity.

Quality: Sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable.Slide29

Thought

Processes-WORKING ONSlide30

Documenting Strengths

Strengths:

insight into current situation/ status

healthy hobbies/ interests/ coping skills

cooperative when talking with you, are they asking for help, do they seem honest throughout the interview?

did they give up things they could or have harmed themselves with?

how have they managed to cope in the past?Slide31

Summary of Assessment

Response Plan-Risk Factors/Warning Signs Identified:

WORKING ON THIS SECTIONSlide32

Summary of Assessment

Response Associated with the outcome

State what the outcome is

Why other tiers were ruled out

Any other important information

Who agreed with this plan

How long is this plan in effect

Who will participateSlide33

Example of Tiers Outline

The client was not appropriate to remain home alone, due to her continued suicidal thoughts, plan and attempt this day.

The client was not appropriate for a telephone stabilization plan in her home due to her home being the location of her medications(unwilling to have someone secure) and no available supports with her current suicidal ideation and plan

The client was not appropriate for a community response plan with supports as supports identified refused to provide supervision and client refused to go with supports or have supports be with herSlide34

Tiers Continued

A crisis bed was explored and discussed however, the client refused to go voluntarily to the crisis bed.

A voluntary admission to a inpatient hospital was discussed and the client stated she did not need a hospital and adamantly stated “I don’t need or want any help”

An emergency detention was approved on this date under criteria for Mental Illness as evident by self reported diagnosis of bi-polar disorder as well as “hopelessness”. Dangerousness to Self as evidence by consumption of a full bottle of alprazolam and being found unresponsive. Continued risk of dangerousness as client indicated frustration that her attempt did not work “clearly I need to take more”.Slide35

Sample Response Plan :

John is remaining in the community with the support of his sister tonight . Although John confirmed

that

he had sent that text to his sister he denied it was a presentation of suicidal ideation or intent. He stated his

intent was

to

express his desire to no longer

be living and fighting at his girlfriends. He stated he understands his sisters concerns given his history of suicidal threats about eight years prior.

John

was also able to identify

the

plan for the night, and

Suzie Q(sister)

agreed

John could remain with her and she would be home for the next 24 hrs. to provide support.

She said she felt comfortable contacting emergency services at a later time if further concerns presented themselves

.

John also agreed to contact emergency services if he needed assistance.

John identified intent to contact his previous therapist about possible appointment on Monday.

Officer Smith

and this worker were in agreement that James would be safe to remain in the community tonight. Slide36

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Additional Items Addressed in Response plan

Recommendation to secure firearms communicated to:

Recommendation to secure other potential hazards such as medications communicated to:

Location of Bed (hospital, crisis bed, CSCN):

Admission Confirmed

Admission Confirmation Plan Created

Transportation provided by:

Client is going to Jail:

Precautions recommended and communicated to:

Recommendation that no precautions were needed

No recommendations were communicated

Medical Treatment Primary – Location:

Telephone Stabilization Plan CreatedSlide38

Signatures

Signatures need full name and credentials.

Typing your name is not a signatureSlide39

Credentials

Credential or qualifications are defined as follows:

Anyone with a mental health related Master’s degree or above should sign with their degree abbreviation (MA, MSW, PhD., etc.).

All licensed professionals should sign with the appropriative abbreviation for their license.

Anyone with a Bachelors Degree in a human service related field should sign with their degree (BA, BS, etc.).

If someone has a set of circumstances that does not neatly fit on this guide, please check with your supervisor who will direct you what to putSlide40

Documentation Time Expectations

It is the expectation of Northwest Connections that billable documentation time shall not exceed 45 minutes in time. This expectation was developed by reviewing content and documentation that is currently being provided.

If you are struggling to meet this expectation reach out to a supervisor

This may be difficult when first starting out.Slide41

Documentation Submission

Documentation is due to the county by 8am on the next business day.

Each county documentation submission option(s) may be a bit different.

We understand that there are situations that can lead to a need for documentation to be late on occasion. Due to the nature of county employees follow up and linkage expectations you must contact your county contact person if you are going to be late in documentation submission.

Note-documentation is your typed assessment-your notes from your assessment are not to be sent.Slide42

What is due to the County?

Typed crisis assessment- including your signature

Mobile Specific:

Crisis Assessment

Crisis Assessment Signature

Response Plan

Release of Information

Rights and Grievances signature page

Any County Specific Items

Your notes do not need to be turned into the county. Slide43

Confidentiality in the Community

Create a password protected User Account for personal computers being used – see computer items handout

Any documents with client information must be kept in a locked/secured area no one has access to

Vehicle – lock in trunk

Desk or other location at home – locked in desk drawer, file cabinet, etc.

Remember you can save blank forms on your computer to use; you just cannot have forms with consumer information on your computer. Slide44

Security on a personal computer-Mobile

Click on start

Go to the

Control Panel

Select

User Accounts

Select

Manage Another Account

Click

Add a New User

Enter a name for User

Select

Administrator account type;

if a password is currently used you will have to enter it

Click

Create Account

Upon creating account; again go back to

User Accounts

Click

on the account you just created

Click

Add/Change your Password

Enter a password – do not share this desktop with others

See mobile computer handoutSlide45

Mobile-Saving the Assessment

Complete document on your desktop and “save as”

Smith, John.mobile.01.10.13 Slide46

Mobile-Supporting Documents

If scanning documents separately — save on desktop as:

If a Mobile Crisis Assessment –

Smith, John.mobile.01.10.13

If a Mobile Crisis Assessment Signature –

Smith, John.signature.01.10.13

If a Mobile Crisis Response Plan –

Smith, John.response.01.10.13

If a Mobile Assessment Release of Information –

Smith, John.ROI.01.10.13

If a Mobile Assessment Rights and Grievances page –

Smith,John.rights.01.10.13

If a County Specific Items –

Smith,John.other.01.10.13

If scanning all items together

Smith,John.mobileitems.01.10.13Slide47

Destroying documentation(mobile)

It is important to destroy any documents you create or obtain related to a client after contact.

Please verify that the documents have been received prior to destroying any documentation.

Hard copies: Proper disposal of client paperwork is shredding or burning. Slide48

Destroying documentation

Deleting items from your desk top: It is imperative that if you work from home on a personal computer that following inputting your documentation you delete that document off of your hard drive. To do this:

Select the document hold down shift and delete

Select yes when “Are you sure you want to delete...” comes up

Remember you can save

blank

forms on your computer to use, you just cannot have forms with client information on your computerSlide49

Using our PortalSlide50

County Specific PacketsSlide51

Onsite-Carbon Response Plan

Complete, review/ read response plan with all parties and have everyone sign it

Distribute copies to all involved parties- a copy should go home with the client so they remember what they agreed to

Consider follow up and include in the plan

Keep a copy for your records and to demonstrate good faith effort. Document with whom and how you communicated or consulted. Does your documentation demonstrate your best faith effort

Samples of the carbon response plan are located in your training binderSlide52

References and Resources

http://www.youtube.com/watch?v=9ViaBgG7sMwSlide53
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