Documentation: Assessment, Treatment Plans & Progress Notes - PowerPoint Presentation

Documentation: Assessment, Treatment Plans & Progress Notes Presented by Jill S. Perry, MS, NCC, LPC, CAADC, SAP August 23, 2017

What does COD Look Like? JP Counseling Healing for Adults, Youth and Families

JP Counseling Healing for Adults, Youth and Families

Actual Medical Quotes The patient had waffles for breakfast and anorexia for lunch. The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately. The patient was in his usual state of good health until his airplane ran out of gas and crashed. I saw your patient today, who is still under our car for physical therapy.

Actual Medical QuotesThe patient lives at home with his mother, father, and pet turtle who is enrolled in day care three times a week. Examination of the genitalia was completely negative except for the right foot. While in the emergency room, she was examined, X-rated and sent home. The skin was moist and day.

Actual Medical Quotes The lab test indicated abnormal lover function. Coming from Detroit, this man has no children. Patient was alert and unresponsive.When she fainted, her eyes rolled around the room. Rectal exam revealed a normal size thyroid.

Keep Taking the Medicine Patient: It's been one month since my last visit and I still feel miserable . Doctor: Did you follow the instructions on the medicine I gave you ?Patient: I sure did - the bottle said 'keep tightly closed.'

SAMHSA Addiction Counseling Competencies The recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client-related data. 1. Demonstrate knowledge of accepted principles of client record management. 2. Protect client rights to privacy and confidentiality in the preparation and handling of records, especially in relation to the communication of client information with third parties. 3. Prepare accurate and concise screening, intake, and assessment reports.4. Record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.5. Record progress of client in relation to treatment goals and objectives.6. Prepare accurate and concise discharge summaries.7. Document treatment outcome, using accepted methods and instruments.

Purposes of Clinical DocumentationTo document professional work: To record what was done, by whom, with, to, for, and/or on behalf of whom, when, where, why, and with what results To document assessment and differential diagnosis, treatment and other services provided, the patient's clinical course and clinical decision making (including assessment-based treatment and service planning and periodic reviews and modifications of the treatment/service plan)

Purposes of Clinical Documentation—Organization of Care T o serve as the basis for organization and continuity of care of the patient by the practitioner:To record clinically meaningful information that the practitioner can later rely on to refresh his or her memory of crucial events in treatment, the patient's response to treatment and other services, problems experienced in treatment, key historical facts and details of substantive collateral contactsTo create a longitudinal record of the history of the patient’s complaints, symptoms, comorbidities, assessments, diagnoses, treatment and other services provided, clinical course, and response to treatment and other services so that the treating practitioner and other practitioners who are, or who later become involved in working with the patient can use this information to identify potential trends, guide their assessment and guide their development and implementation of their treatment/service plans To provide a basis for practitioner reflection and self-supervision on the patient's evaluation, diagnoses, treatment and services, assessment-based treatment/service plan, clinical course and progress

Purposes of Clinical Documentation—Continuity of Care T o serve as the basis for subsequent continuity of care of the patient by recording for use by other practitioners who may serve the patient in the future clinically meaningful data regarding the patient’s:A ssessment, diagnoses, treatment and other services provided, clinical course, progress and response to treatment and other services Assessment-based treatment and service plans and the periodic reviews and modifications of those plansTrends, crises and problems in treatment, so that they may have sufficient data based upon which they can provide meaningfully clinically informed continuity of care to the patient;

Purposes of Clinical Documentation—Risk Management F or risk management purposes to protect against malpractice lawsuits and professional discipline complaints, and to aid in defending effectively against any such lawsuits or complaints (in this regard, be aware that if you didn’t document something of importance in the patient’s clinical record and that becomes the subject of contention in a legal or disciplinary proceeding against you, it can be treated by a court or administrative body as if it did not happen or you missed it or you ignored it or you did not address it, etc.,)

Purposes of Clinical Documentation—Risk Management T o document informed consent (i.e., for treatment, disclosure of information) and the nature and extent of the professional relationship and of duty owed with regard to the patient To explain, detail and justify professional decision-making, problems encountered in working with the patient, and the professional response to crises and other special or problem situations To record the details of supervision/consultation obtained in relation to the assessment and treatment of the patient, particularly with regard to crises or other special or problematic situations that ariseFor supervisors (who are legally professionally responsible and accountable for the professional services provided by their supervisees) to document each of their supervisory sessions, each of their contacts with the patients whose care they are supervising, and their oversight of the assessments, treatment and other services rendered by their supervisees under their supervision in order to enable them to defend the quality and appropriateness of their supervision and the quality of their supervisee’s professional work against any malpractice lawsuit or professional discipline complaint alleging negligent supervision or malpractice by them or their supervisee To record information that will support the adequacy of the clinical assessment, the appropriateness of the treatment/service plan and the application of professional skills and knowledge in the provision of professional services To substantiate the treatment/services provided and the results of such treatment/services

Purpose of Clinical Documentation--ComplianceT o comply with legal, regulatory and institutional requirementsTo ensure compliance with clinical documentation and recordkeeping requirements imposed by federal and state (including licensing boards) laws, regulations and rules To ensure compliance with clinical documentation and recordkeeping standards set by specific accreditation programs (i.e., JCAHO) and by health care institutions, facilities and agencies To fulfill clinical documentation and recordkeeping requirements of various third-party payers (i.e. Medicare, Workmen's Compensation, Medicaid, insurance, managed care plans);

Purpose of Clinical Documentation—Quality Assurance/Utilization Review T o facilitate quality assurance and utilization reviewT o record professional activities, the process and substance of assessment, differential diagnosis, treatment and service planning, clinical decision-making and the results of treatments and other services provided To document the appropriateness, clinical necessity and effectiveness of treatments and other services providedTo substantiate the need for further assessment, testing, treatment and/or other services, or to support changes in or termination of treatment and/or servicesTo facilitate supervision, consultation and staff/professional developmentTo help improve the quality of services by identifying problems with service delivery by providing data based upon which effective preventative or corrective actions can be undertaken to improve and assure the quality of careTo provide data for use in planning educational and professional development activities, policy development, program planning and research in agency settings To provide data to guide choices of continuing professional education programs to attend, ongoing review and revision of the organization and operation of the practitioner’s professional practice and research in private practice settings

The Role of Clinical Documentation in Quality Assurance Having to prepare proper clinical documentation serves an important role of helping ensure quality patient care by making practitioners think about their patients, review and reflect on their therapeutic interventions, consider the efficacy of their clinical work and weigh alternative approaches to the care of their patients. The capacity for professional self-reflection and self-appraisal of one's professional work is essential to a practitioner’s professional development, to the maintenance of his or her professional skills and to the provision of high quality clinical services. Rather than viewing clinical documentation as a meaningless chore that consumes precious time, practitioners should view it in this light, as a form of self-supervision that is an essential element of their professional practice and of their provision of quality clinical services.

Purpose of Clinical Documentation--CoordinationT o facilitate coordination of professional efforts by fostering communication and collaboration between members of the treatment teamT o ensure coordinated rather than fragmented treatment/service deliveryTo ensure appropriate utilization of team members from multiple disciplines in order to bring to work collaboratively in an interdisciplinary/transdisciplinary manner the particular competencies of team members from various disciplines and/or who have specific specialties to maximize the quality of services to patients.

ELEMENTS OF GOOD CLINICAL DOCUMENTATION—Recording & Organization Clinical documentation should be recorded and organized as follows : 1) Each page of a patient record should have the patient’s name clearly printed or typewritten on the top. 2) ALL entries in the patient record should be signed (either in handwritten form or electronic form) by the practitioner making the entry. 3) Entries in the patient record should be written contemporaneously with the events they are documenting. 4) Each entry in a patient record should be dated the day it is written.

ELEMENTS OF GOOD CLINICAL DOCUMENTATION—Recording & Organization 5. If an entry in a patient record documents an interview, therapy session, missed session, any follow-up of the missed session, assessment or other substantive patient related collateral contact (i.e.; with another treating practitioner, with a family member, with the parents of a child who is in treatment) that took place earlier than the day the entry is written, the entry should include clear documentation of the day the activity being documented occurred . 6) Any materials or information received regarding a patient which are entered in the clinical record should be dated and initialed on the day the information or material is initially reviewed and placed in the patient record. Additionally, a progress note should be written to document the review of the material or information and any action taken as a result of that review. 7) All substantive collateral contacts with others relating to the patient and all referrals made relating to the patient should be documented contemporaneously in the patient’s clinical record. Timely follow-up on any referral made should be documented in the patient’s clinical record.

ELEMENTS OF GOOD CLINICAL DOCUMENTATION—Recording & Organization 8) The record should be kept neatly, in date order for each section, in at least the following sections : a ) basic contact and demographic information about the patient b) intake information including demographic and contact information about the patient c) progress notes, initial and interval updates of treatment/service plans and closing/termination summary d) referrals made, tests requested, and the reports of consultations, referrals or test results which are received

ELEMENTS OF GOOD CLINICAL DOCUMENTATION—Recording & Organization e ) communications with other practitioners received or sent relating to the patient f) non-professional correspondence to or from the patient or from non-professional collateral contacts g) billing records including copies of bills provided to patients, claims submitted to third-party payors, correspondence with patients and third-party payors relating to billing and payments

ELEMENTS OF GOOD CLINICAL DOCUMENTATION—Recording & Organization h . A chronological financial ledger by date: (1) of services rendered - with the following information for each service [including separate services rendered on the same day]: date of service(s), description of service(s) with CPT [Current Procedural Terminology] codes, if the charge for a service is based on time spent the amount of time spent, and the charge(s) for the service(s)(2) of financial transactions with the following information, the date and amount of the financial transaction, the nature of the transaction [payment, payment of coinsurance, denial of payment in whole or in part by third-party payor, etc.], the source of the transaction [patient, parent or guardian of patient, insurance or managed care third-party payor, etc.), write-off of charges and reason(3) Running outstanding balancei. Documents relating to HIPAA compliance, informed consent for treatment documents, consents and authorizations for use and/or disclosure of clinical information and records

Elements of Good Clinical Documentation - WritingClinical documentation should be written in a manner that is well organized and that allows rapid location, recovery and utilization of clinical and other information about the patient. Writing good, useful clinical documentation requires thinking about and reflecting on the event(s) being documented in the context of the patient’s history and condition, the treatment and services being provided, and the patient’s treatment/service plan.

Elements of Good Clinical Documentation - Writing 1) Provides relevant information in appropriate detail 2) Is organized with appropriate headings and logical progression3) Is thoughtful, reflecting the application of professional knowledge, skills and judgement in the treatment/services provided 4) Is appropriately concise 5) Serves the purposes of clinical documentation

Elements of Good Clinical Documentation - Writing 6) Uses relevant direct quotes from the patient and from other sources identified as such by utilizing quotation marks 7) Distinguishes clearly between facts, observations, hard data and opinions 8) States the source(s) of the facts, observations, hard data, opinions and other information being relied upon, and provides an assessment of the reliability of that material9) Is internally consistent 10) Is written in the present tense, as appropriate

Biopsychosocial Model

Biopsycosocial Model Developed by George L. Engel (American Psychiatrist—1977) States that interactions between biological, psychological, and social factors determine the cause, manifestation, and outcome of wellness and diseaseHistorically, popular theories like the nature versus nurture debate posited that any one of these factors was sufficient to change the course of development. The biopsychosocial model argues that any one factor is not sufficient; it is the interplay between people's genetic makeup (biology), mental health and behavior (psychology), and social and cultural context that determine the course of their health-related outcomes.

Biological Influences on HealthMany disorders have an inherited genetic vulnerability. The greatest single risk factor for developing  schizophrenia, for example, is having a first-degree relative with the disease (risk is 6.5%)

Psychological Influences on Health  Depression on its own may not cause liver  problems, but a person with depression may be more likely to abuse alcohol, and, therefore, develop liver damage. Increased risk-taking leads to an increased likelihood of disease.

Social Influences on HealthSocial factors include  socioeconomic  status,  culture, technology, and religion. For instance, losing one's job or ending a romantic relationship may place one at risk of stress  and illness. Such life events may predispose an individual to developing depression, which may, in turn, contribute to physical health problems. The impact of social factors is widely recognized in mental disorders like anorexia nervosa (a disorder characterized by excessive and purposeful weight loss despite evidence of low body weight). The fashion industry and the media promote an unhealthy standard of beauty that emphasizes thinness over health. This exerts social pressure to attain this "ideal" body image despite the obvious health risks. 

Social Readjustment Scale

Culture as a Social InfluenceC ultural factors D ifferences in the circumstances, expectations, and belief systems of different cultural groups contribute to different prevalence rates and symptom expression of disorders. For example, anorexia is less common in non-western cultures because they put less emphasis on thinness in women.

Culture as a Social InfluenceCulture can vary across a small geographic range, such as from lower-income to higher-income areas, and rates of disease and illness differ across these communities accordingly. Culture can even change biology, as research on epigenetics is beginning to show. Specifically, research on epigenetics suggests that the environment can actually alter an individual's genetic makeup. For instance, research shows that individuals exposed to over-crowding and poverty are more at risk for developing depression with actual genetic mutations forming over only a single generation. 

Maria

Example: Biomedical ModelReason for visit : Maria complains of chest pain. Presentation: The focus is on physical causes of disease. The clinician will ask few questions on recent diet, pain history, and familial incidence, however, empirical signs and symptoms of myocardial infarction are considered paramount. Diagnosis: The clinician will recommend objective lab tests and monitor vital signs (i.e. temperature, pulse, and blood pressure) that would form the sole basis of any diagnosis. Therapy: The clinician would refer Maria to a doctor to prescribe a medicinal plan for the patient based on biological etiology and pathogenesis.

Example: Biopsychosocial ModelReason for visit : Maria complains of chest pain. Presentation: The aim is to ascertain psychosocial and physical processes that may cause the chief complain, chest pain. The clinician may ask for a history of recent life stressors and behaviors. Diagnosis: Based on a combination of psychological factors and standard lab tests, the clinician will form a diagnosis. Therapy: The clinician discusses the available interventions with special attention to behaviors and lifestyles that could influence her pain and adherence to the treatment plan. Maria is involved in formulating and implementing the plan, and maintains a supportive relationship with the clinician.

Mental Status Exam

What is the Mental Status Examination (MSE)? May be viewed as the psychological equivalent of the physical exam A snapshot of the patient at a given timeObservations noted throughout the interview become part of the MSE, which begins when the clinician first meets the patient. Information is gathered about the patient’s behaviors, thinking, and mood.

George

GeorgeA 55-year-old man presented with recent complaints of sadness and fear of being alone. He also expressed thoughts about death. As he presented his concerns, he rambled to unrelated topics and seemed to lose track of the interviewer’s questions. During the formal inquiry he was able to recall only 1 of 3 objects he was asked to memorize and made several mistakes in serial subtractions of 7 from 100. Specific questioning about suicidal wishes and actions revealed that he had overdosed with aspirin 1 month earlier and still experienced suicidal thoughts and wishes to die.

GeorgeThe cognitive tests were compatible with mild dementia, and the differential diagnosis included major depression. Further work-up and treatment supported this diagnosis. Cognitive functioning improved with antidepressants.

Is the MSE a separate part of the patient evaluation? No . The MSE must be interpreted along with the presenting history, physical exam, and lab and other reports. Separate interpretation makes you vulnerable to erroneous conclusions. Collateral information from families and friends may be invaluable to confirm or supply missing data.

Jane

JaneA 27-year-old woman presented to the psychiatric emergency department with somewhat grandiose behavior, pressured speech, irritability, and psychomotor agitation. The initial diagnostic impression was bipolar disorder, manic or drug induced mania. The patient denied drug abuse. However, questioning her wife uncovered a history of substance abuse, and laboratory evaluation revealed the presence of amphetamine metabolites. The correct diagnosis was amphetamine-induced mood disorder.

What key factors should be considered along with the MSE? To assess properly the patient’s mental status, it is important to have some understanding of the patient’s social, cultural, and educational background. What may be abnormal for someone with more intellectual ability may be normal for someone with less intellectual ability. Patients for whom English is a second language may have difficulty understanding various components of the MSE. Age may be a factor. In general, patients over the age of 60 years tend to do less well on the cognitive elements of the MSE. Often this is related to less education rather than to aging alone.

Major Components of the MSE Appearance M otor activitySpeechAffect Thought contentThought processPerceptionIntellectInsight

Major Components of the MSEMemory can be assessed by asking about news events, sports, television shows, or recent meals. Long-term memory can be assessed by using past events confirmed by family members and also by repeating names of historical figures, such as presidents of the U.S. Language ability can be assessed by asking patients to explain similarities and differences between common objects (e.g., tree-bush, car-plane, air-water). Thinking processes can be assessed by asking patients to explain common proverbs (ie—”two wrongs don’t make a right”) with which they are familiar.

Does the MSE Establish Competence? No. Competence relates to patients’ ability to make reasonable decisions for themselves and others. Such decisions include ability to provide food and shelter, to manage money, and to participate in activities such as deciding a course of medical care. Patients who score well on an MSE may have still deficits in understanding or completing common tasks of daily living and may, therefore, not be competent. Among a population with a probable diagnosis of Alzheimer’s disease, 50% of patients had no difficulty with the MSE but had significant trouble with basic tasks such as coping with small sums of money or finding their way around familiar streets. The MSE is only one component needed to assess competency. Medical condition, current ability for self-care, and corroborating information from family or friends must be taken in consideration.

Mental Status Exam Mini Mental Status Exam

You’re a Good Man Charlie Brown Lunch Time

Screening

Screening & Assessment for ALL Disorders is Necessary Because... Having one disorder increases the risk of developing another disorder; The presence of a second disorder makes treatment of the first more complicated; Treating one disorder does NOT lead to effective management of the other(s);Treatment outcomes are poorer when co-occurring disorders are present.JP CounselingHealing for Adults, Youth and Families

Know Your Limitations…. Counselors should understand the limitations of their licensure or certification authority to diagnose or assess mental disorders. Generally, however, collecting screening & assessment information is a legitimate and legal activity even for unlicensed providers, provided that they do not use diagnostic labels as conclusions or opinions about the clientJP CounselingHealing for Adults, Youth and Families

Basic Screening & Assessment Must Address: M edical issues (including physical disability and sexually transmitted diseases)Cultural issues Gender-specific issuesSexual orientation issuesLegal issuesJP CounselingHealing for Adults, Youth and Families

Screening Screening is a formal process of testing to determine whether a client does or does not warrant further attention at the current time in regard to a particular disorder. The screening process seeks to answer a “yes” or “no” question: Does the substance abuse (or mental health) client being screened show signs of a possible mental health (or substance abuse) problem? Note that the screening process does not necessarily identify what kind of problem the person might have or how serious it might be, but determines whether or not further assessment is warranted. JP CounselingHealing for Adults, Youth and Families

Screening Protocol Screening processes always should define a protocol for: Determining which clients screen positiveScreening Tool Cut-off ScoresEnsuring that those clients receive a thorough assessmentWho Performs the AssessmentDocumentationJP CounselingHealing for Adults, Youth and Families

Specific Screening Areas Suicidality Trauma ViolenceAddictionChemicalProcess Mental Health DisordersDepressionAnxietyPost-Traumatic Stress

Specific Screening Areas The counselor should know what immediate onsite and offsite resources are available to help with someone identified as positive in a screening. Establish standardized protocols and staff training around screening, assessment, intervention and/or triage: Who asks?  What  is  asked?  When  is  this done? When does this take place? How is this documented? What is done with the results?JP CounselingHealing for Adults, Youth and Families

Suicidality All clients in rehab or mental health facilities should be screened. The counselor should know his or her own skills and limitations in engaging, screening, assessing and intervening with suicidal clients. Work out these issues before an emergency. Providers  are  advised  to  develop  clear answers  to  the  following  questions:  Do  you  or your  agency  have  the  knowledge,  tools,  skills, and  personnel  for  crisis  stabilization  and/or ongoing  work  with  suicidal  clients?  How  suicidal  can  clients  be  and  still  be  retained  in your  practice  or  agency?  What  about  suicidality  that  emerges  later  in  treatment  or  in conjunction  with  a  relapse? JP CounselingHealing for Adults, Youth and Families

It is best to ask clients about suicide directly Research does not support that asking about suicide will put that idea in their mind Questions could include: “In the past, have you ever been suicidal or made a suicide attempt?” “Do you have any of those feelings now?”

IS PATH WARM I = Ideation S = Substance abuse P = PurposelessnessA = AnxietyT = TrappedH = Hopelessness W = WithdrawalA = AngerR = RecklessnessM = Mood changes JP CounselingHealing for Adults, Youth and Families

SuicidalityIf a client is screened positive for suicidality, he or she should not be left alone until someone appropriate can determined the level of risk. Suicide “contracts” are written statements in which the person who is suicidal states that he will not kill himself, but rather call for help, go to an emergency room if he becomes suicidal. These contracts are not effective as the sole intervention for a client who is suicidal . While such contracts often help to make the client and therapist less anxious about a suicidal condition, studies have never shown these contracts to be effective at preventing suicide. What good contracts really do is help to focus on the key elements that are most likely to keep clients safe, such as agreeing to remove the means a client is most likely to use to commit suicide.

Trauma ScreeningRegardless of the setting, all clients should be screened for past and present victimization and trauma. In screening for a history of trauma or in obtaining preliminary symptoms of post-traumatic stress, it can be damaging to ask the client to describe traumatic events in detail. All questions should avoid “retraumatizing” the client.

To screen, it is important to limit questioning to very brief and general questions: “Have you ever experienced childhood physical abuse? Have you ever experienced s exual abuse? Have you ever experienced a serious accident? Have you ever experienced violence or the threat of it? Have there been experiences in your life that were so traumatic they left you unable to cope with day-to-day life?JP CounselingHealing for Adults, Youth and Families

Violence Screening Questions 1. What kinds of things make you mad? What do you do when you get mad? 2. What is your temper like? What kinds of things can make you lose your temper? 3. What is the most violent thing you have ever done and how did it happen? 4. What is the closest you have ever come to being violent? 5. Have you ever used a weapon in a fight or to hurt someone? 6. What would have to happen in order for you to get so mad or angry that you would hurt someone? 7. Do you own weapons like guns or knives? Where are they now?

CAGESubstance Abuse Screening Have you ever felt you should cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use?Have you ever felt bad or guilty about your drinking?Have you ever had a drink or drug first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

Mental Health Screening Form-III

Mental Health Screening Form IIIInstructions: In this program, we help people with all their problems, not just their addictions. This commitment includes helping people with emotional problems. Our staff is ready to help you to deal with any emotional problems you may have, but we can do this only if we are aware of the problems. Any information you provide to us on this form will be kept in strict confidence. It will not be released to any outside person or agency without your permission. If you do not know how to answer these questions, ask the staff member giving you this form for guidance. Please note, each item refers to your entire life history, not just your current situation, this is why each question begins –“Have you ever ....”

Mental Health Screening Form III1) Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about an emotional problem 2 ) Have you ever felt you needed help with your emotional problems, or have you had people tell you that you should get help for your emotional problems? 3) Have you ever been advised to take medication for anxiety, depression, hearing voices, or for any other emotional problem?4) Have you ever been seen in a psychiatric emergency room or been hospitalized for psychiatric reasons?

Mental Health Screening Form III5) Have you ever heard voices no one else could hear or seen objects or things which others could not see? 6 ) a) Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble concentrating and making decisions, or thought about killing yourself? b) Did you ever attempt to kill yourself? 7) Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible event? For example, warfare, gang fights, fire, domestic violence, rape, incest, car accident, being shot or stabbed?

Mental Health Screening Form III8) Have you ever experienced any strong fears? For example, of heights, insects, animals, dirt, attending social events, being in a crowd, being alone, being in places where it may be hard to escape or get help? 9 ) Have you ever given in to an aggressive urge or impulse, on more than one occasion, that resulted in serious harm to others or led to the destruction of property ?10) Have you ever felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior?

Mental Health Screening Form III11) Have you ever experienced any emotional problems associated with your sexual interests, your sexual activities, or your choice of sexual partner? 12 ) Was there ever a period in your life when you spent a lot of time thinking and worrying about gaining weight, becoming fat, or controlling your eating? For example, by repeatedly dieting or fasting, engaging in much exercise to compensate for binge eating, taking enemas, or forcing yourself to throw up? 13 ) Have you ever had a period of time when you were so full of energy and your ideas came very rapidly, when you talked nearly non-stop, when you moved quickly from one activity to another, when you needed little sleep, and believed you could do almost anything?

Mental Health Screening Form III14. Have you ever had spells or attacks when you suddenly felt anxious, frightened, uneasy to the extent that you began sweating, your heart began to beat rapidly, you were shaking or trembling, your stomach was upset, you felt dizzy or unsteady, as if you would faint? 15 ) Have you ever had a persistent, lasting thought or impulse to do something over and over that caused you considerable distress and interfered with normal routines, work, or your social relations? Examples would include repeatedly counting things, checking and rechecking on things you had done, washing and rewashing your hands, praying, or maintaining a very rigid schedule of daily activities from which you could not deviate. 16) 1.Have you ever lost considerable sums of money through gambling or had problems at work, in school, with your family and friends as a result of your gambling? 17) Have you ever been told by teachers, guidance counselors, or others that you have a special learning problem?

Assessment

Assessment is a process for defining the nature of the problem(s) and developing specific treatment recommendations for addressing the problem(s). JP Counseling Healing for Adults, Youth and Families

Purposes of Basic Assessment Provides key information for treatment matching & treatment planning Offers a structure to obtain the following: Basic Demographic & historical information Identification of established or probable diagnosis and associated impairmentsGeneral strengths & problem areasStage of change for both SU & MHPreliminary determination of the severity of COD as a guide to final level of care determinationJP CounselingHealing for Adults, Youth and Families

Purposes of Basic AssessmentBackground—family, trauma history, history of domestic violence (either as a batterer or as a battered person), marital status, legal involvement and financial situation, health, education, housing status, strengths and resources, and employment Substance use—age of first use, primary drugs used (including alcohol, patterns of drug use, and treatment episodes), and family history of substance use problems Mental health problems—family history of mental health problems, client history of mental health problems including diagnosis, hospitalization and other treatment, current symptoms and mental status, medications, and medication adherence JP CounselingHealing for Adults, Youth and Families

Purposes of Basic AssessmentDetailed chronological history of past mental symptoms, diagnosis, treatment, and impairment, particularly before the onset of substance abuse, and during periods of extended abstinence Detailed description of current strengths, supports, limitations, skill deficits, and cultural barriers related to following the recommended treatment regimen for any disorder or problemTo determine stage of change for each problem, and identify external contingencies that might help to promote treatment adherence.JP CounselingHealing for Adults, Youth and Families

Assessment of the client with COD is an ongoing process that should be repeated over time to capture the changing nature of the client’s status. Assessments must be continuous and monitored and revised as the client moves through recoveryJP CounselingHealing for Adults, Youth and Families

All assessments should include routine procedures for identifying and contacting any family and other collaterals who may have useful information to provide. Process of seeking such information must be carried out strictly in accordance with applicable guidelines and laws regarding confidentiality and with the client’s permission. JP Counseling Healing for Adults, Youth and Families

All assessment must include some specific attention to the individual’s current strengths, skills, and supports, both in relation to general life functioning, and in relation to his or her ability to manage either mental or substance use disorders. JP Counseling Healing for Adults, Youth and Families

Questions might focus on: Talents and interests Areas of educational interest and literacy; vocational skill, interest, and ability, such as vocational skills, social skills, or capacity for creative self-expression Areas connected with high levels of motivation to change, for either disorder or both Existing supportive relationships, treatment, peer, or family, particularly ongoing mental disorder treatment relationshipsJP CounselingHealing for Adults, Youth and Families

Previous mental health services and addiction treatment successes, and exploration of what worked Identification of current successes: What has the client done right recently, for either disorder? Building treatment plans and interventions based on utilizing and reinforcing strengths, and extending or supporting what has worked previously Questions might focus on:

Questions to Ask… How are your substance abuse and mental health problems defined by your parents? Peers? Other clients? What do they think you should be doing to remedy these problems? How do you decide which suggestions to follow? In what kinds of treatment settings do you feel most comfortable? What do you think I (the counselor) should be doing to help you improve your situation? JP CounselingHealing for Adults, Youth and Families

JP Counseling Healing for Adults, Youth and Families Questions to Ask… What does the client want? What is the treatment contract?What are the immediate needs?What are the diagnoses? Identify which assessment dimensions are most severe to determine treatment priorities.Choose a specific priority for each medium/severe dimension.

Questions to Ask… What specific services are needed to address these priorities? What “dose” or intensity of services is needed? Where can these services be provided in the least intensive, but safe, level of care or site of care? How will outcomes be measured?What is the progress of the treatment plan and placement decision?

The Clinician’s RoleHighly publicized acts of violence by people with mental illness affect more than public perception. Clinicians are under pressure to assess their patients for potential to act in a violent way. Although it is possible to make a general assessment of relative risk, it is impossible to predict an individual, specific act of violence, given that such acts tend to occur when the perpetrator is highly emotional. During a clinical session, the same person may be guarded, less emotional, and even thoughtful, thereby masking any signs of violent intent. And even when the patient explicitly expresses intent to harm someone else, the relative risk for acting on that plan is still significantly influenced by the following life circumstances and clinical factors.

The Clinician’s Role Although, in most settings, the majority of clients do not pose a significant risk for violence, an inquiry into aggressive and violent behavior should be made with each new client A client’s inability to maintain her composure or control her anger and irritability in the context of a clinical interview may say much about her ability in real life settings

The Clinician’s RoleClinicians are encouraged to think about violence risk in conditional terms (i.e., “If . . . , then . . . .”) and offer opinions in this way when they are required T he conceptualization of violence risk as something that can change over time, across conditions, or in response to various interventionsThe risk assessment perspective, as compared to “dangerousness prediction” and its associated language and conceptualization, facilitates incorporation of information about violence risk into treatment planning.

Key Questions in a Suicide/Violence Risk Review What is wrong? Personal narrative about how bad things are and the nature of the problem(s)Personal construction of reasons for suicide/violence Personal measure of psychological pain and suffering Why now? Elements of the current crisis History of real or imagined losses or rejections Sudden and unacceptable changes in life circumstances; for example, the client just received a serious or terminal diagnosis, relapse, onset of possible symptoms (e.g., sleeplessness) With what? The means of suicide/violence under consideration Access to the means selectedJP CounselingHealing for Adults, Youth and Families

Key Questions in a Suicide/Violence  Risk  Review Where and when? Possible location and timing of a suicide/violence Degree of planning Possible anniversary phenomena When and with what in the past? Past history of suicidal/violent behavior Past history of intense suicidal/violence ideation and/or planning Whether rescue was avoided Timing of past attempts Social response to past attempts Potential protective factors Comparison of current method versus old methodJP CounselingHealing for Adults, Youth and Families

Key Questions in a Suicide/Violence Risk Review Who’s involved? Others who may know or be involved Persons who may or may not be helpful in managing the client Names of potentially helpful third parties Possible presence of a suicide pact or murder-­suicide plan Why not now? One or more protective factors (reasons for living) Spiritual or religious prohibitionsJP CounselingHealing for Adults, Youth and Families

Beck’s Suicide Inventory

Suicide Risk Assessment Tool

Trauma Assessment Tool

Diagnosis Principle #1: Diagnosis is established more by history than by current symptom presentation. This applies to both mental and substance abuse disorders. If there is evidence of a disorder but the diagnosis/treatment recommendations are unclear, the counselor should immediately begin the process of obtaining this information from collaterals.

Sally

JP Counseling Healing for Adults, Youth and Families Sally EXAMPLE #1: Sally comes into you office under the influence of alcohol, it is reasonable to Substance Use Disorder, but the only diagnosis that can be made based on that circumstance is “alcohol intoxication.” It is important to note that this warrants further investigation; on the one hand, false positives can occur, while on the other, detoxification may be needed.

Brady

BradyEXAMPLE #2: Brady comes into your office and has not had a drink in 10 years, attends Alcoholics Anonymous (AA) meetings three times per week, and had four previous detoxification admissions, a diagnosis of Substance Use Disorder (in remission at present ) can be made. Moreover, you can predict that 20 years from now that client will still have the diagnosis of Substance Use Disorder since this is a lifetime diagnosis.

Valerie

JP Counseling Healing for Adults, Youth and Families Valerie EXAMPLE 3: If Valerie comes into your office and says she hears voices (whether or not she is sober currently), no diagnosis should be made on that basis alone. There are many reasons people hear voices. They may be related to substance-related syndromes (e.g., substance-induced psychosis, which includes the experience of hearing voices that the client knows are not real, and that may say things that are distressing or attacking—particularly when there is a trauma history—but are not bizarre).

Oscar

OscarEXAMPLE 4: If Oscar states he has heard voices, though not as much as he used to, that he has been clean and sober for 4 years, that he remembers to take his medication most days though every now and then he forgets, and that he had multiple psychiatric hospitalizations for psychosis 10 years ago but none since, then Oscar clearly has a diagnosis of psychotic illness (probably schizophrenia or schizoaffective disorder). Given his continuing symptoms while clean and sober and on medication, it is quite possible that the diagnosis will persist.

DiagnosisPrinciple #2: It is important to document prior diagnoses and gather information related to current diagnoses, even though a counselor may not be licensed to make a mental disorder diagnosis.

Diagnoses established by history should not be changed at the point of initial assessment. If the clinician has a suspicion that a long-established diagnosis may be invalid, it is important that he or she takes time to gather additional information, consult with collaterals, get more careful and detailed history and develop a better relationship with the client before recommending diagnostic re-evaluation. JP Counseling Healing for Adults, Youth and Families

JP CounselingHealing for Adults, Youth and Families Diagnosis Principle #3 : For diagnostic purposes, it is almost always necessary to tie mental symptoms to specific periods of time in the client’s history, in particular those times when active substance use disorder was not present .

Inquire whether any mental symptoms or treatments identified in the screening process were present during periods of 30 days of abstinence or longer, or were present before onset of substance use. Determination of both current and baseline functional impairment contributes to identification of the need for case management and/or higher levels of support. This step also relates to the determination of level of care requirements. JP Counseling Healing for Adults, Youth and Families

Assessment Summary

The Documentation of a Proper I nitial A ssessment1) Identification of the referral source(s), gathering information about the background and reasons for the referral and assessing the patient's response to and expectations with regard to the referral; 2) Defining the presenting problem(s) and what the patient wants to accomplish in treatment, both in the patient's own words using appropriate quotes (identified by using quotation marks), as well as in terms of the practitioner's perception of the presenting problem(s) and needs of the patient;

The Documentation of a Proper Initial Assessment 3) Detailing the history and clinical course of presenting problem(s) and the details of treatment or services the patient has sought or received to deal with those problems in the past (either in the long term or in the immediate past); 4) Gathering and documenting relevant history from the patient and from collateral sources, in appropriate detail, by topic, identifying the sources of such historical information and assessing the reliability of the information, regarding:

The Documentation of a Proper Initial Assessment a ) Family history including a list of family members in families of origin and procreation and basic demographic information about them (i.e., age, birthplace, education, occupation, age, and cause of death if applicable), a brief description about their relationship with the patient, marital history, and any family history of mental, neurological, substance abuse/alcoholism or serious medical problems; b) Medical history including details of serious or chronic ailments, hospitalizations, serious physical trauma and/or surgery, allergies or adverse drug reactions; any physical disabilities and how the patient has and/or is coping with them; any chronic medications and all current medications including OTC drugs, supplements, herbs and other alternative treatments, and information about their relationships and feelings about past and current treating practitioners;

The Documentation of a Proper Initial Assessment c) Psychiatric history including details of mental health symptoms, diagnoses and treatments, hospitalizations (including whether voluntary or not), what precipitated or triggered the symptoms, treatment or hospitalization, and the patient’s response to prior mental health treatment (including response to and side effects of particular psychotropic medications that have been prescribed), prior psychotherapy and/or psychopharmacotherapy and the patient’s response to and feelings about psychotherapy and/or psychopharmacotherapy; history of treatment compliance and non-compliance (if patient left treatment, why he or she did so and with what results), details of the degree of the patient’s mental disability and how the patient is coping with this; and information about their relationships and feelings about past and current treating mental health practitioners;

The Documentation of a Proper Initial Assessment d) History of alcohol and other substance abuse and alcoholism and substance abuse treatment including, for each substance of abuse, including alcohol, the substance, the first and most recent use of the substance, the route(s) of use, the amount used/time period (i.e., $10 of crack/day, five 40oz cans of beer/weekend), the frequency of use (i.e., steady on a daily basis, binging once every three of four weeks for one to three days) the duration of use, any significant periods of abstinence (including how these were achieved and why they ended), the social context of the substance abuse (i.e., alone, sharing with others, only at parties), identified triggers for the substance abuse, treatment programs attended (which ones, when and for how long, what the patient liked and disliked about the program, what the patient felt that he or she accomplished and did not accomplish in the program, and whether the patient completed the program successfully, if not, why), and the biopsychosocial impact of the substance abuse on the patient and his or her significant others;

The Documentation of a Proper Initial Assessment e) Child and adolescent developmental history including family and peer group relationships, home life, socio-economic status, schooling, parenting and discipline, type of neighborhood and housing, learning disabilities and other developmental delays (in children and young adolescents a more detailed developmental history is usually indicated); f) Educational history including level of academic achievement, academic strengths and weaknesses, relationships with teachers, history of being denied regular promotion, placement in special education or other special educational programs, school behavior including any suspensions, expulsions or school transfers;

The Documentation of a Proper Initial Assessment g) History of occupational training/skills and work history including significant employment, work related difficulties, how the patient views his or her work, the patient’s career goals, general salary information and adult economic status ;h) History of interpersonal relationships including the nature and extent of peer group relationships, marriages and other close relationships over the life span, what has kept or keeps these relationships functioning, why and how these relationships end, the patient’s reactions and feelings about the end of close interpersonal relationships, the nature and type of any significant interpersonal problems the patient has had or is having;

The Documentation of a Proper Initial Assessment i ) History of past and current social support systems including the nature and impact of these or the lack of these on the patient’s development and functioning; j) Juvenile and criminal justice history including the nature of any arrests, convictions and any sentences imposed, and history of patterns of antisocial behavior; k) History of sexual relationships or psychosexual problems and issues including sexual orientation issues and any sexual dysfunction;l) History of religious affiliation and practices and issues relating to religion;

The Documentation of a Proper Initial Assessment m) Spirituality (aside from religion) including the values, thoughts, emotions, motivations, needs, dreams, experiences, assumptions and relationships that make the person a unique individual, and provide him or her with the vitality, drive and determination to develop and function as a fully actualized person; n) Social issues his or her functioning in relation to other persons and his or her environment including, but not limited to interpersonal and social relatedness, skills and capacity; behavioral responses to environmental, mental and emotional events and stimuli; responsiveness to the environment and to other persons; adaptive functioning and behavior; stress and frustration tolerance and impulse control; linguistic and communicative functioning; social judgement; and the influences of age, culture, customs, disability, discrimination, economic factors, gender, geographic and other environmental factors, health status, illness, injury, loss, national origin, pain and suffering, politics, race and religion his or her development and functioning; and

The Documentation of a Proper Initial Assessment o) History of physical, emotional or sexual abuse or other victimization including where and when these occurred, the patient’s view of the impact of these on his or her life, whom the patient told about these events and the response of people who learned about these occurrences.

Treatment Plans

Treatment PlansRoad map to follow in treatment No 2 road maps should be the same—everybody’s journey is different Must be fluid

Treatment Plans Develop a Problems List Must be evidenced by signs and symptoms Must be measurable“as evidenced by” or “as indicated by”

Treatment Plans Problem 1: Inability to maintain sobriety outside of a structured facility As evidenced by: Blood alcohol level of .23 As evidenced by: The patient’s family report of daily drinking As evidenced by: Alcohol withdrawal symptoms As evidenced by: Third DWI As evidenced by: History of third treatment for addiction

Treatment Plans Problem 2: Depression As evidenced by: Hamilton Depression Rating Scale score of 29 As evidenced by: Psychological evaluation As evidenced by: Patient’s two suicide attempts in the past 3 months As evidenced by: Depressed affect

Treatment PlansProblem 3: Acute alcohol withdrawal As evidenced by: Coarse hand tremors As evidenced by: Blood pressure 160/100, pulse 104 As evidenced by: Restless pacing; self-report of strong craving As evidenced by: Profuse sweating; mild visual disturbances

Treatment Plans Develop Goals Brief clinical statement of the condition you expect to change in the patient More than elimination of pathology Directed toward patient learning new and more functional methods of coping

Treatment Plans Instead of: The patient will stop drinking. Use : The patient will develop a program of recovery congruent with a sober lifestyle. (The patient is learning something different.) Use: The patient will learn to cope with stress in an adaptive manner.

Treatment Plans Instead of: The patient will stop negative self-talk. (The patient does not learn something different or use something differently; the patient just avoids something that he or she already knows.) Use: The patient will develop and use positive self-talk. (Now the patient learns something different that is incompatible with the old behavior.) Use: The patient will develop a positive self-image. (The patient learns something new and more adaptive.)

Treatment Plans Examples of Goals 1 . The patient will learn the skills necessary to maintain a sober lifestyle. 2. The patient will learn to express negative feelings to his or her spouse. 3. The patient will develop a positive commitment to sobriety.

Treatment Plans4. The patient will develop a healthy diet and begin to gain weight . 5. The patient will learn how to tolerate uncomfortable feelings without using chemicals. 6 . The patient will learn to share positive feelings with others. 7. The patient will develop the ability to ask for what he or she wants.

Treatment Plans8. The patient will develop the ability to use anger appropriately. 9. The patient will sleep comfortably on a regular basis. 10. The patient will learn healthy communication skills

Treatment Plans Develop Objectives A specific skill that patient must acquire to achieve a goal Must be measurable

Treatment PlansGoals usually can’t be seen; objective can been seen.Can you see the patient read about Step One in the Alcoholics Anonymous book (2001)? Yes. (Objective) Can you see the patient understand the illness of addiction? No. (Goal) Can you see the patient gain insight? No. (Goal) Can you see the patient complete the Step One exercise? Yes. (Objective)

Treatment PlansCan you see the patient improve his or her self-esteem? Can you see the patient keep a daily record of his or her dysfunctional thinking? Can you see the patient share his or her feelings in group?

Treatment PlansGoal A: The patient will develop a program of recovery congruent with a sober lifestyle, as evidenced by: 1 . The patient will share in the Individual Assignments group three times when he or she tried to stop drinking but was unable to stay sober. 2 . The patient will make a list of the essential skills necessary for recovery

Treatment Plans Goal B: The patient will learn to use assertiveness skills, as indicated by: 1 . The patient will discuss the assertive formula and will role-play three situations where he or she acts assertively. 2. The patient will keep an assertiveness log and will share the log with the counselor daily. 3. The patient will practice assertiveness skills in interpersonal group.

Treatment Plans Develop Interventions What you do to help the patient complete the objective Must be measurable At least 1 intervention for every objective

Treatment Plans Intervention: Assign the patient to write a list of five negative consequences of his or her drug use . *Responsible professional: ____________________ Intervention: In a conjoint session, have the patient share the connection between drinking and marijuana use. *Responsible professional: ____________________

Treatment Plans Intervention: In group, encourage the patient to share his or her anxious feelings. *Responsible professional: ____________________ Intervention : Have the patient develop a personal recovery plan that includes all of the activities that he or she plans to attend. *Responsible professional: ____________________

Treatment Plan Samples

Treatment Plan Updates

Treatment Plan UpdatesProblem 1: Patty continues on her Valium come-down schedule. She has reported only mild withdrawal symptoms. She is sleeping well. She continues to be mildly restless. She was encouraged to increase her level of exercise to 20 minutes daily.

Treatment Plan Updates Problem 2: Patty has completed her chemical use history and Step One exercise. She shared in interpersonal group her powerlessness and unmanageability. She was open in group, and she verbalized that she has accepted her disease of addiction. She was somewhat more reluctant to accept her problem with Valium, but the group did a good job of explaining cross-tolerance. The patient should complete the cross-tolerance exercise and report her findings to the group

Treatment Plan UpdatesProblem 3: The patient continues to take her iron supplement. Her hemoglobin is within normal limits. Problem 4: The patient is over her cold. Problem 4 is completed.

Treatment Plan UpdatesProblem 5: The patient has written a letter to her mother and father describing how she felt about her childhood. The patient shared her letter in group, and she was surprised to find out that many of the other patients had similar experiences. The patient stated that she is feeling more comfortable sharing in group, and she appears to be gaining confidence in herself. Patty met with her counselor, and the counselor encouraged Patty to accept her new AA/NA group as the healthy family that she never had. Patty expressed hope in becoming involved with this healthy family

Treatment Plan UpdatesProblem 6: Patty is working on the relationship skills exercise. She has been practicing asking for what she wants. It is still very difficult for her to share some of her feelings, particularly her anger, in group. When she shares her anger, she tends to feel guilty.

Treatment Plan UpdatesProblem 7: Patty completed the honesty exercise and the chemical use history that opened her eyes to how dishonest she has been. Patty made a contract with her group to be honest and asked the patients to confront her if they felt that she was being dishonest. Patty is keeping a daily log of her lies and when she is tempted to lie. She has been able to identify many lies she was telling in her life and is able to verbalize her understanding of how her lies keep her isolated from others.

Treatment Plan UpdatesProblem 8: Patty is working on the assertiveness skills exercise. She is practicing the assertive formula. She tends to feel guilty when she says no, but she is getting better at it. She will say no to someone five times a day for 3 days and keep a log of how she feels about each situation.

Progress Notes

Sheldon’s Psychotherapy Session

Progress NotesLegal and ethical standards clearly state that therapists must maintain some kind of record of the treatment they provide The Documentation Function of Progress Notes In the simplest terms, progress notes are brief, written notes in a patient’s treatment record, which are produced by a therapist as a means of documenting aspects of his or her patient’s treatment. Progress notes may also be used to document important issues or concerns that are related to the patient’s treatment. 

Progress NotesThe first function or purpose of a progress note is to record services provided by a staff member. Progress notes are the primary source of data indicating that a service was delivered. The second function of a progress note is to document the course of treatment ; i.e., progress or lack thereof related to a treatment intervention. Both functions of the progress note are essential elements of evidence based practices.

Progress NotesGood progress notes begin with effective treatment planning. If more work is given to the proactive development of an effective treatment intervention, less work will be needed in documenting those services. T horough and comprehensive treatment planning leads to easy documentation in progress notes, whereas poorly developed treatment planning leads to extensive documentation in progress notes (or worse, incomplete or unclear documentation of services).

Progress NotesC ontent , length and complexity of progress notes should vary, depending upon the particular therapy session. In other words, an event that transpires in a given therapy session may be especially critical or noteworthy, in comparison to another session.  P rogress notes are brief, written notes that are utilized to document a patient’s treatment and various related issues, including treatment planning, documenting the necessity of treatment and demonstrating the appropriateness, competency and yes, hard work of the therapist.

Documenting Competent Treatment  The treatment record is a formal recording of the assessment and treatment rendered to a patient by his/her therapist. As one component of the patient’s treatment record, progress notes allow a therapist to describe his or her work with a patient. Without progress notes, it would be difficult, if not impossible, for a therapist to create a health care record that accurately reflects his or her sound clinical judgment, the standards of the profession, and the nature of the services being rendered. Furthermore, progress notes provide a therapist with an opportunity to document his or her exercise of judgment in dealing with complex and challenging treatment scenarios.

Documenting Competent Treatment Progress notes may reflect a therapist’s ongoing efforts to assess and manage his or her patient’s symptoms, or demonstrate his or her therapeutic skill in responding to complex risk factors. In addition, should a therapist’s conduct be challenged by the patient or by the Board, progress notes may help to establish that his or her conduct was ethical and lawful.

Documenting Treatment Necessity Progress notes provide evidence of the patient’s need for treatment at a particular point in time. As an example, an insurer or similar entity may require a provider to document the “medical necessity” for treatment in the patient’s record. Treatment programs or clinics are routinely visited by utilization-review staff who review treatment records, including progress notes, for documentation of medical necessity.

Documenting Treatment Necessity Billing/payment documentation: In the event of a dispute over the amount or type of services rendered, progress notes substantiate the fact that professional mental health services were rendered on a given date and that the therapist’s billing was consistent with the nature of services rendered .

Documenting Treatment Necessity Standards of third parties Psychotherapists regularly enter into agreements with third parties such as insurance companies or managed care organizations. A therapist who elects to contract with such entities should be aware of the organization’s specific practice guidelines and/or treatment standards. In contrast to the general legal and ethical standards cited earlier, these guidelines and standards often contain specific requirements for documentation of mental health services, including progress note entries. Practice guidelines and like documents are often accessible to providers via the organization’s Internet website.

Evidence Based Practice for Progress Notes Collaborative relationship. All evidence-based interventions in mental health and addiction treatment are based on a collaborative relationship between an individual with an identified need (e.g., help overcoming a substance use disorder, depression, or related issues, such as assistance finding a job) and a direct service provider (e.g., addiction counselor, recovery coach, case manager, or job coach) or team of providers. This principle implies that the two individuals work together to solve problems, achieve goals, and overcome barriers to goals.

Evidence Based Practice for Progress Notes Person centered planning. A related principle to the collaborative relationship is a focus on person-centered planning. Person-centered planning implies that the consumer/client is given control over his or her treatment and that all treatment interventions are selected to help this individual achieve self-defined goals. This principle also implies that direct service providers are consultants working with individuals, rather than experts with the authority to select interventions without partnering with clients/consumers.

Evidence Based Practice for Progress Notes Goal directed services. All evidence-based interventions are designed to achieve specific outcomes or treatment goals. Evidence-based interventions are usually manualized, highly structured, and based on a set of guidelines. Even if an intervention is not designated as an evidence-based intervention, such as case management or peer-driven services, it is still being used to accomplish a goal. This implies that a goal needs to be identified in order to provide services. Stated another way, services are not provided when a goal has not been identified.

Evidence Based Practice for Progress Notes Measurable and reasonable goals. This principle indicates that the goals-outcomes (short- & long-term) selected by consumers and direct service providers need to be observable, measurable, within the individual’s capacity (i.e., reasonable), & logically connected to the intervention being implied. This principle also implies that direct service providers and consumers need to avoid selecting goals/outcomes that are difficult to observe, measure, or beyond the capacity of the individual.

Air Travel Video

4 Types of ContactsEngagement & treatment planning. This is usually the first activity that occurs between a direct service provider and consumer/client (crisis contacts occasionally occur before this activity). This activity occurs before any treatment intervention has been established or delivered and can reoccur over time (at least the treatment plan development part). Treatment plan development can include monitoring behaviors to establish a baseline rate for a particular target behavior. Engagement is an individualized process, but it is not an unlimited activity. If direct service providers are unable to engage individuals within a reasonable amount of time (e.g., 4 to 8 weeks in a community-based model), change the plan or service provider.

4 Types of Contacts Service delivery. After a working relationship has been developed and a treatment plan has been established, the next logical series of service contacts are activities associated with a particular treatment intervention. Frequency, intensity, and duration of contacts are based on consumer preference and the particular intervention that is being used.

4 Types of Contacts Crisis-based interactions. Crisis-based contacts are, by default, unplanned or unpredicted contacts outside the established treatment plan. In addition, to meet the criteria of “crisis”, the individual will require assistance that cannot be delayed or diverted. Many direct service providers erroneously label predicted or expected behaviors as a crisis. Most crisis events are actually predictable events that were not addressed in the treatment planning process. For example, a relapse of alcohol or other drugs for an individual who recently completed addiction treatment is not unexpected. In addition, if a behavior occurs frequently (more than two or three times), it is, by default, not a crisis, but rather a predictable behavior that requires an intervention. Most of these mislabeled events will probably fall under the first activity of treatment plan development (e.g., need to revise plan to address ongoing behavior) or service delivery (e.g., relapse prevention or planned assertive outreach due to a relapse).

4 Types of ContactsClosure or transition. All effective or evidence-based interventions have a beginning and an end-point. Closure activities are used to praise individuals for completing a particularly treatment intervention as well as achieving a planned goal, and helping them to either move on to the next goal or close services. If the intervention does not have an end-point, it cannot be evaluated. If an intervention cannot be evaluated, it’s probably ineffective or, worse, detrimental to the client/consumer. Transitioning activities can also be used to end an intervention that has shown to be ineffective and modify the treatment plan to try another technique.

Progress NotesA pplication of the 3 Ws (who, where, & when)All progress notes begin with a list of individuals involved in the activity, where the activity occurred, and when (include the total amount of time involved in the activity).

Elements of Documentation of a Treatment Session Depending on the evolving circumstances of each case, certain purposes of documentation will be more crucial than others at various points in treatment. For instance, if a patient's mental status deteriorates and he or she becomes threatening, the purpose of carefully documenting the practitioner's professional response and clinical decision-making and the purpose of risk management/malpractice protection will predominate. In a case where a patient who has significant medical, family and mental health problems is being served by several different practitioners, documentation dealing with coordination of the professional efforts of the various practitioners will predominate.

Elements of Documentation of a Treatment Session A proper progress note, which need not be particularly extensive, in most cases merely several sentences, should include : 1) the date and length of the contact; 2) the specific services provided, including CPT [Current Procedural Terminology] descriptions and codes; in the case of other non-clinical services (i.e., case management, advocacy, referral, etc.) indicate the service(s) in words; 3) description of the type of contact (i.e.; in person, telephone, mail); 4) indication of who initiated the contact (i.e.; regularly scheduled session, patient showed up without appointment, phone call by patient, phone call by patient's family who put patient on the phone, inquiry from another practitioner/service provider who is with the patient in the emergency room and puts the patient on the phone);

Elements of Documentation of a Treatment Session 5) statement of where the contact took place (i.e.; office, if a home visit - the address visited, if by phone - the phone number called); 6 ) indication of who, besides the patient, was involved in the contact (i.e.; patient, family, other practitioner, friend); 7) a description of the themes of the session, in generic terms, addressing particular symptoms, feelings, thinking, beliefs or behaviors (i.e., pain, anxiety, dysphoria, suspiciousness, avoidance, etc.) or relating to specific relationships or situations (i.e.; work problems, interpersonal relationships, parent-child problems, marital relationship, school problems, the effects of chronic physical illness); 8) an assessment of the patient’s mental status during the session, relating this to the patient’s baseline mental status and the patient’s mental status in the recent past;

Elements of Documentation of a Treatment Session 9) notation of any symptoms or complaints that may indicate a physical health problem (i.e., side effects of psychotropic medication, sleep problems, confusion); 10 ) description of any new significant history obtained; 11) description of relevant problems newly identified; 12) description of relevant significant new events (i.e., changes in medication, results of tests, exacerbation of a concurrent physical ailment, break-up of a relationship, beginning new relationship); 13) description of therapeutic interventions with clinical justification and reasoning to support these in relation to the treatment plan and clinical circumstances, particularly when in response to crisis situations or special/markedly changed circumstances;

Elements of Documentation of a Treatment Session 14) statement of what was accomplished in the session; 15 ) statement of what wasn't accomplished in the session that needs to be followed up on; 16) details of obstacles to progress in treatment, if any, and a plan to address these; and 17) a description of a plan for further care or follow-up (including date and time of next appointment), changes in diagnosis and/or treatment plan/goals, if any, and reasoning to support these changes (particularly when in response to crisis situations or special/markedly changed circumstances) and any referrals made or testing ordered (including the nature of the referral, to whom the referral is made, the reason for the referral, tests ordered and the reason they were ordered, and the patient’s response to the referral and/or ordering of tests).

Documenting Progress of TreatmentEvaluating the outcome of the activity requires minimal effort and writing when delivering a well developed treatment intervention. On the other hand, a poorly developed treatment intervention will lead to an increase in effort, time, and writing in order to evaluate an activity. It is difficult to evaluate an activity if it is unclear why the activity was delivered. In other words, if you are lost in the woods, it is difficult to know if you are making progress toward finding a way out.

Documenting Progress of Tx Evaluating an activity requires only a few, clear statements about the expected goal. These statements include: A brief note about the expected goal (e.g., the goal today was to improve the skill of saying no to alcohol by role playing and modeling assertiveness skills for saying no to family members ) A brief note about the outcome (e.g., After several role plays [we both switched the roles], Carol was able to comfortably say no to multiple requests for drinking without stuttering or becoming passive) A brief note about the next step (e.g., Carol is going home this weekend and has agreed to write down any situations where she will be asked to have a drink and what she does about the request. Carol also has a backup plan of calling her sponsor if she struggles to say no to a family member)A brief note about the next appointment (e.g., we decided to meet next Monday to review how Carol used the skill of saying no and if it helped her avoid drinking over the weekend).

Documenting Progress of Tx Another example: • A brief note about the expected goal (e.g., John selected the goal of submitting two job applications by today without my help) • A brief note about the outcome (e.g., John submitted one job application, but his car broke down before he could drop off the second one at the department store) • A brief note about the next step (e.g., John wants to complete the step, so he is going to have his brother help him fix his car by next week. If he can’t fix the car by Friday, he will call me and I will give him a ride to the department store to drop off the job application) • A brief note about the next appointment (e.g., we decided to meet next Tuesday, if John doesn’t call me this Friday, to practice interviewing for when he gets a chance to talk to an employer).

Elements of Documentation of a Treatment Session A good progress note is clear, brief, and linked to the treatment plan. In essence, the progress note tells a simple and easy to follow story about a treatment intervention and an individual’s response to the intervention over time. Progress notes are used to report only on the outcome of the intervention and are not used as a diary of conversations or a verbatim recording of each session

Common Errors in Progress NotesRecording dialogue between clinician and client (e.g., the client said ……. and then I said……. and the client responded by saying…….). Dialogue is rarely necessary to record and will lead to wasted time writing an extended note. Conversations are expected to occur with the intervention, but the details of the conversation are usually not necessary to record. It is okay and often useful to summarize important information noted by clients/consumers in the session, but only when the information is relevant (and new) to the established treatment plan (e.g., the client noted that her ex-boyfriend is getting out of prison next week and that he is a “big” trigger for her using cocaine).

Common Errors in Progress NotesRecording detailed reports of what occurred in the session (e.g., on the first role play, Carol was unable to ……… so I tried it again, this time I said …………, after that try Carol then tried to…………). Details are not needed, particularly if the outcome was achieved, as planned. If the intervention or activity did not produce the desired result, simply report that it didn’t work and try something else. The progress note is not used to record that the clinician understands how to implement the activity; that is the job of a supervisor.

Common Errors in Progress NotesRecording excessive or extraneous details associated with the planned activity or reasons for why the activity did not occur or was not completed (e.g., John explained to me that he thinks the fuel pump in his car needs to be repaired or that ………, he told me that he called his brother about the problem and his brother said……..). Excessive or extraneous details of behaviors are not necessary when they are not directly related to the intervention or planned activity. Simply note that John’s car is broken and that he has a plan to get it fixed (or not). Summary statements are easier to follow and comprehend and should be used to organize detailed information in the progress note.

Common Errors in Progress NotesRecording details about repetitive behaviors (e.g., Julie called me again this week telling me about the argument she had with her father, Julie explained that her father ……….., which led to Julie wanting to hurt herself, again, by …………………). Even if the behavior is the target of an intervention, such as learning how to be assertive, reducing the need to self-mutilate, reducing drinking, learning how to manage anger or avoid negative people, it is not necessary to provide extensive detail about the behavior, particularly if the behavior has been explained at least once in the form of a functional analysis.

Common Errors in Progress Notes Writing an extensive note that correlates with the amount of time spent with clients. Some direct service providers feel compelled to write long notes if they spend an extensive amount of time with clients during an activity. Teaching someone how to shop for healthy and affordable food, accompanying a client to an AA meeting, looking for an affordable apartment, or learning how to ride a bus while managing panic attacks can take hours to complete (and multiple opportunities to practice the skills), but the progress note needs only to state that these skills-training services were delivered and the consumer’s response to the training/intervention (e.g., apartment or job acquired, increase time in the store while having a panic attack and not running out of the store, client understands bus schedule will try it on his own tomorrow, needs more training, or not effective at behavior change). A four-hour, evidence-based activity and a 15-minute conversation will require about the same amount of words and space on a sheet of paper (or field in a computer).

Common Errors in Progress Notes Using vague or ambiguous terms to describe target behaviors, goals, or interventions. Commonly used and abused words in progress notes include: Motivation: avoid the term, except when referring to Motivational Interviewing. Instead of using the word motivation, which often implies that the person is choosing not to be motivated (i.e., lazy), describe the destination that a person will reach (e.g., entering treatment) or the activity that they will perform (e.g., walk around the block twice this week). Quality of life: be specific instead of using this term. What aspect of quality of life (e.g., housing, safety, relationships, health, or leisure activities) will the person address? Self-esteem: this is a ambiguous term that cannot be observed and is rarely related to anything but self-esteem scales. Again, what aspect of self-esteem is being addressed; e.g., body image, depression, self-destructive thoughts, the impact of stigma, or relationship issues? There are multiple effective cognitive-behavioral and behavioral techniques that can be used to address negative thoughts and behaviors, but only if the specific thought or behavior is identified. Self-esteem is colloquial and over-used term within Western culture.

Common Errors in Progress Notes Happy or happiness: Happiness cannot be measured and, even if this emotional/psychological state could be reliably measured, it is a fairly unstable emotion or thought. Instead, focus on what will make the individual happy and in their words? You cannot reliably measure increased or decreased happiness, but you can reliably measure activities, such as time with children (or significant others), access to social events, participation in leisure activities, or learning a new hobby that will impact happiness (if the consumer selects these activities). Compliant (e.g., Medication compliant): this is an outdated medical-model term that should not be used when developing a person-centered plan. Compliance does not exist in a collaborative relationship. Do you ask your husband/ boyfriend or wife/ girlfriend to be more compliant with your demands in the relationship? Even physicians understand that they can’t order their patients to be more compliant, but they can work with them to improve adherence to the medication regimen.

Common Errors in Progress Notes Satisfaction: another commonly abused term that is usually used to describe a consumers’ evaluation of the clinician’s activity. Surprisingly, most consumers are satisfied with most activities, even if the treatment is not helpful or needed. The purpose of working with clients/consumers is to help them achieve treatment goals, not to be satisfied with the clinician. If clients are achieving their self-defined goals, they will likely be satisfied; nonetheless, satisfaction should not be used as a proxy measure for treatment effectiveness or for the appropriateness of treatment. Independence (or empowerment): There are multiple effective interventions designed to improve individuals’ independence in the community, such as supported employment, education, and housing. Nonetheless, all these interventions lead to specific outcomes, such as obtaining a competitive job, completing a degree, or living in an apartment for a specific amount of time (and reducing rates of institutionalization). Instead of using the words independence or empowerment, select the specific activity that will promote these two broad terms

Common Errors in Progress NotesAddiction or addictive behaviors (or substance use/abuse behaviors): These terms can be used in a treatment plan, but even within the treatment plan, the objectives will need to specify the behavior being addressed as well as the target drug (i.e., the drug of choice). Avoid using broad terms, such as substance use behaviors or addictions (or mental illness), and describe the specific behavior that was addressed in the activity, such as saying no to a drug dealer, discussing the pros & cons of entering treatment, finding leisure activities that don’t require alcohol, identifying triggers, listing negative thoughts that lead to drug use, or engaging supportive family members in the treatment process.

Examples of Information that Therapists May Want to Include in Progress Notes Treatment modality usedProgress, and/or lack of progressTreatment planModification(s) of the treatment planClinical impressions regarding diagnosis, and or symptomsRelevant psychosocial informationSafety issues; danger to self/others

Examples of Information that Therapists May Want to Include in Progress Notes Clinical emergencies/actions taken Medications used by the patient Treatment compliance/lack of complianceClinical consultationsCollaboration with other professionalsTherapist’s recommendationsReferrals made/reasons for making referrals

Examples of Information that Therapists May Want to Include in Progress Notes Termination/issues that are relevant to the termination process Issues related to consent and/or informed consent for treatment Information concerning child abuse, and/or elder or dependent adult abuseInformation reflecting the therapist’s exercise of clinical judgment.

Impression & Plan Should be NEW and UPDATED every day • Most important part of the note • Not necessary to include all stable problems • Identify your plans • Be specific • Avoid “to consider” • Use if/then statements instead • Each problem should have a separate plan

Impression & Plan Use your plan to communicate what you need to know • What questions do you need your consultants to answer? • What are you troubled by? • Should be a working document!

Do’s & Don’ts of Progress Notes  Be concise.  Document all necessary information but avoid extraneous details, such as in this example: “Patient moved to Kansas at age 4. Her parents separated when she was 6 and they moved back to Chicago, then reunited and moved to Indiana, where father took a job as a shoe salesman. When he lost that job, they moved back to Chicago and divorced for good. Mother remarried a fireman, who was an alcoholic; they stayed together for 2 years until …” Instead, simply write:“Patient’s childhood was chaotic with many moves; her mother remarried x 3. No physical or sexual abuse …”

Do’s & Don’ts of Progress Notes  Include adequate details.  Do not exclude information critical to explaining treatment decisions. Describe the symptoms the patient is reporting and the signs you see—or do not see. This example offers insufficient detail:“Patient’s parents told her that they just bought a new car. She recalled the first car they had gotten when she was little, and how that made her happy. She talked about the first car she owned. Plan: Add lithium …” By contrast, the following example explicitly describes signs and symptoms. Also be sure to include a short explanation when changing, discontinuing, or adding a medication:“Patient reports her mood is much improved. She cannot recall what made her feel so depressed last week. She is hyperverbal, talking rapidly, gesticulating as she talks—much more animated, as compared to psychomotor-retarded presentation of last week, when SSRI was started. Assess: Bipolar switch. Plan: Add lithium, 300 mg bid, and titrate.”

Do’s & Don’ts of Progress Notes Be careful when describing treatment of a patient who is suicidal at presentation.  Your notes must contain clear, well-reasoned explanations for: discontinuing suicide precautionsnot hospitalizing outpatients who express suicidal ideationand record the patient’s exact response.

Do’s & Don’ts of Progress Notes If the patient attempts or commits suicide shortly after the visit, your progress note may be your best—and only—defense against a malpractice claim. This example offers no convincing argument that the patient will not attempt suicide: “Patient reports that he feels better. He denies suicidal ideation. He thinks the antidepressant is working. Nursing notes indicate no problems. He would like to get dressed and take a walk outside …” Instead, verbatim patient statements offer more-concrete proof that the patient wants to live: “He said he is his family’s sole support and could never abandon them …”“He said it would kill his mother if he took his own life …”“She said suicide is against her religion …”Simply writing “No evidence of suicidal/homicidal ideation” raises the question of whether you asked the patient if he or she has considered suicide or just looked for a sign indicating suicidality. Always ask

Do’s & Don’ts of Progress Notes Remember that other clinicians will view the chart  to make decisions about your patient’s care. Consider this example: “Patient just moved to this area and requests amitriptyline and chlorpromazine. The risks of combining these medications were explained to him, but he insisted, so will order.”If another provider is to grant the patient’s request, more details are needed: “Patient states that he has been on every antipsychotic and antidepressant on the market—including the newest drugs—over 20 years. He says nothing works for him except this combination. The potential anticholinergic and other severe adverse effects associated with this combination were explained to him, and his responses indicated that he clearly understands the risks. He states, ‘These are the only drugs that have kept me from hearing voices and being depressed and suicidal. I want to stay on this combination.’ ”

Do’s & Don’ts of Progress NotesWrite legibly.   Historically many doctors are encouraged to write illegible notes as a defense against legal action. The reasoning: the defendant can testify to anything since no one can read the notes anyway.Illegible notes annoy and frustrate the people who cannot read them and inspire a lack of trust and confidence in the doctor who wrote them. And they are not likely to fool a jury.

Do’s & Don’ts of Progress Notes Respect patient privacy.  Do not name or quote anyone who is not essential to the record. Identifying another patient by name or Social Security number—even the last 4 digits—is a breach of privacy. For example: “Charlene claimed R2803 followed her into the rest room and raped her…”Did patient R2803 actually do this? What if Charlene’s psychosis prompted her to make delusional claims about other patients and staff? If her case ends up in court, patient R2803 is named in connection with an unproven allegation. Naming R2803 in Charlene’s chart identifies him as a psychiatric patient at that facility, thus violating his privacy.

CLINICAL DOCUMENTATION & RECORDKEEPING IN GROUP / FAMILY / CONJOINT THERAPY Even when a patient is being seen in group, family or conjoint therapy, the patient must have his or her own patient record. The practice of writing one note for each group, family or conjoint session and then placing a copy of that note in the chart of each patient who participated in the session is not appropriate, even if each patient is referred to only by his or her initials in the one note. Additionally, notes of group, family or conjoint therapy that are placed in a patient’s record should be kept separate from, and written on a separate page than any notes relating to individual therapy sessions. In this manner, if a patient’s clinical record must be disclosed, this can be accomplished easily without disclosing information about other persons with whom he or she is receiving group, family or conjoint therapy.

CLINICAL DOCUMENTATION & RECORDKEEPING IN GROUP / FAMILY / CONJOINT THERAPY For documentation of a group, family or conjoint therapy session, a note which reflects the information that should be documented in a general progress note as indicated above should be written and should be supplemented by addition of comments about the patient’s functioning in the group/family/couple session and his or her reactions and responses in the context of the group/family/couple process. The progress/session note for each person in the group, conjoint or family therapy, should focus on that individual’s mental status, behavior, participation and functioning in the session, and their reactions and responses to the themes and processes that arose during the session. It should avoid, to the extent possible, mentioning any identifiable material from or about other particular members of the group, couple or family, unless this is necessary for clarity. In writing an individual group therapy note for each group member, only the name of the individual group member whose note is being written should appear in that note.

CLINICAL DOCUMENTATION & RECORDKEEPING IN GROUP / FAMILY / CONJOINT THERAPY In the case of group therapy the number of patients attending the group session should be documented in the progress/session note, along with the initials of the other patients who attended. A separate attendance list of the patients in each group, by session (date of service) should be filed in a group therapy record folder so that there is a record of which patients attended which group and when. In the case of family and conjoint treatment, the very nature of the treatment involves specific identifiable persons. Thus, to protect the privacy of those persons as much as possible in case a patient’s record must be revealed at some point, the persons, other than the patient in whose chart the progress/session note is being placed, should be referred to without using their names. The note written for each patient in the family or couple should focus on the family/couple dynamics as they impact on that individual patient. Before such a family/conjoint therapy record is disclosed, the practitioner should obtain a HIPAA compliant informed consent from each person age 12 or over who is identified as a patient, even if only by their position in the family/relationship, before disclosing the family/conjoint therapy record kept for the patient in question.

Progress NotesTherapists occasionally utilize progress notes to refresh their recollection of clinical information from prior therapy sessions. This review may be particularly helpful when an extended period of time has elapsed since the last patient contact. Also, in some treatment settings, such as community clinics that are staffed by interns, a patient may receive services from different therapists during one continuous treatment episode. In such an instance, progress notes provide a source of clinical information that informs a therapist about the efficacy of clinical interventions that may have been utilized earlier in the patient’s treatment.

Discharge Summaries

Elements of an Appropriate Interval or Closing/Termination SummaryAn interval or closing/termination summary, which may be abbreviated or elongated depending on the circumstances of a particular case, documents the practitioner’s thoughtful reflection on the clinical course of the patient’s treatment (to date in relation to an interval summary, or with regard to the entire period of treatment in relation to a closing/termination summary). Such summaries can be useful if the patient later seeks treatment from another practitioner and requests that a summary be sent to that practitioner. The documentation of a proper interval or closing/termination summary, includes:

Elements of an Appropriate Interval or Closing/Termination Summary 1) The dates the patient was referred, first contacted the practitioner and was first seen, the referral source, and the time period covered by the summary (if this is a closing/termination summary, the date the patient was last seen and the last contact with the patient); 2 ) A synopsis of the initial reason for and background circumstance of the referral, the presenting problem(s) from the patient’s perspective at intake, the patient’s initial clinical presentation, and the initial assessment, including the initial diagnoses and initial identified problems as identified by the practitioner;

Elements of an Appropriate Interval or Closing/Termination Summary 3) A review of the problem areas and symptoms addressed in treatment, the treatment modalities used, of the patient’s clinical course in treatment during the treatment period in question (noting changes, if any, in the patient’s symptoms, thinking, emotions, beliefs, behaviors and other areas of biopsychosocial functioning), and of the extent that the identified symptoms/problems were resolved and the treatment goals established were achieved during the treatment period in question; a brief assessment of the patient’s condition at the end of the time period in question; and, if this is an interval summary, a notation explaining any changes in diagnosis, prognosis, or the treatment/service plan; 4) A summary of any concurrent treatments, including the provider(s) of such treatments, the names and dosages of medications prescribed, other treatments rendered or any other relevant assessments performed; the steps taken to coordinate care with other practitioners (including the extent and success of achieving collaboration, or any problems that interfered with collaborative efforts), the results of any referrals made or testing ordered, and the impact/results of the other concurrent treatments;

Elements of an Appropriate Interval or Closing/Termination Summary 5) A statement regarding the circumstances of the termination of treatment (precipitants, was it planned or unplanned?, was it mutually agreed upon by patient and the practitioner?, did the patient stop coming and, if so, what steps were taken to address this and with what results); 6 ) Final diagnoses and a statement as to the patient’s functioning, as well a statement as to which, if any, of the concurrent treatments (including medication) the patient is receiving the patient intends to continue (if so, from whom and to what extent) and does not intend to continue (if so, what are the patient’s reasons for discontinuation of those services);

Elements of an Appropriate Interval or Closing/Termination Summary 7) A statement detailing any referrals or recommendations provided to the patient regarding further care, and the patient’s response to such referrals and recommendations; and 8) A statement of whether the patient poses a risk of decompensation, suicidality, assaultiveness, homicidality, relapse back to alcoholism or substance abuse, inability to care for himself or herself, of being victimized, of victimizing others, or is at any other serious risk at the time of termination/closing, the basis of the risk assessment, details of the steps taken to address any of these risks, and the results of such steps.

“The written word is the greatest sacred documentation.”  ―   Lailah Gifty Akita,  Pearls of Wisdom: Great mind