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

Documentation: Assessment, Treatment Plans & Progress Notes Jill S. Perry, MS, NCC, LPC, CAADC, SAPApril 5, 2019JP Counseling & associates, LLC701 Sharon Road, Suite 2Beaver, pa 15009724-494-6750www.jpcounselingcenter.org

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

JP Counseling & Associates, LLC Healing for Adults, Youth and Families

5 Rules to Eliminate Stigma Who remembers?????JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Rules to Eliminate Stigma DON’T: Label people who have a mental illness or addictionBe afraid of people with mental illness or addictionUse disrespectful terms for people with mental illness or addictionBe insensitive or blame people with mental illness or addiction JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Rules to Eliminate StigmaDO:Be a role model

Employ a Recovery Perspective JP Counseling & Associates, LLC Healing for Adults, Youth and Families Recovery is a long-term process of internal change Recovery involves internal changes that proceed through various stages.

JP Counseling & Associates, LLC Healing for Adults, Youth and Families

JP Counseling & Associates, LLC Healing for Adults, Youth and Families

JP Counseling & Associates, LLC 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Actual Medical Quotes I saw your patient today, who is still under our car for physical therapy.The 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Actual Medical Quotes While in the emergency room, she was examined, X-rated and sent home.The skin was moist and dry.The lab test indicated abnormal lover function. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Actual Medical QuotesComing 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.'JP Counseling & Associates, LLC Healing for Adults, Youth and Families

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.Demonstrate knowledge of accepted principles of client record management.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.Prepare accurate and concise screening, intake, and assessment reports. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

SAMHSA Addiction Counseling CompetenciesRecord treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.Record progress of client in relation to treatment goals and objectives.Prepare accurate and concise discharge summaries.Document treatment outcome, using accepted methods and instruments.

Purposes of Clinical Documentation

To 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 resultsTo 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) JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Organization of Care 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 contacts JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Organization of CareTo 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

Organization of Care 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Continuity of Care

clinically meaningful data Assessment, 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 JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Risk Management

Risk Management To protect against malpractice lawsuits and professional discipline complaintsTo aid in defending effectively against any such lawsuits or complaints JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Risk Management***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.

Risk Management To 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 patientTo 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 arise JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Risk ManagementTo 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

Risk Management For 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Compliance

Compliance To 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., TJC) 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) JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Quality Assurance & Utilization Review

Quality Assurance/Utilization Review To 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 services JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Quality Assurance/Utilization ReviewTo 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 care JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Quality Assurance/Utilization ReviewTo provide data for use in planning educational and professional development activities, policy development, program planning and research in agency settingsTo 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

Quality Assurance/Utilization ReviewHaving 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Quality Assurance/Utilization ReviewRather 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.

Coordination

Coordination Fostering communication and collaboration between members of the treatment teamTo ensure coordinated rather than fragmented treatment/service delivery JP Counseling & Associates, LLCHealing for Adults, Youth and Families

CoordinationTo 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 Each page of a patient record should have the patient’s name clearly printed or typewritten on the top. ALL entries in the patient record should be signed (either in handwritten form or electronic form) by the practitioner making the entry. Entries in the patient record should be written contemporaneously with the events they are documenting. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Recording & OrganizationEach entry in a patient record should be dated the day it is written.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. - JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Recording & OrganizationAny 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, some documentation should be written regarding the review of the material or information and any action taken as a result of that review.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.

Recording & OrganizationThe record should be kept neatly, in date order for each section. A sample order would include the following sections: a) basic contact and demographic information about the patient b) intake information including demographic and contact information about the patient JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Recording & Organizationc) 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 e) communications with other practitioners received or sent relating to the patient

Recording & Organization 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 (sometimes these are in a separate file) JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Recording & Organizationh. 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 balance JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Recording & Organizationi. Documents relating to HIPAA compliance, informed consent for treatment documents, consents and authorizations for use and/or disclosure of clinical information and records

Writing Clinical 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Writing Provides relevant information in appropriate detail Is organized with appropriate headings and logical progressionIs thoughtful, reflecting the application of professional knowledge, skills and judgement in the treatment/services provided Is appropriately concise JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Writing Uses relevant direct quotes from the patient and from other sources identified as such by utilizing quotation marks Distinguishes clearly between facts, observations, hard data and opinions JP Counseling & Associates, LLCHealing for Adults, Youth and Families

WritingStates 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 material Is internally consistent

Biopsychosocial Approach JP Counseling & Associates, LLC Healing for Adults, Youth and Families

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 disease JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Biopsycosocial ModelHistorically, 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.JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Biological Influences on Health Many 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%) JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Social Influences on Health Social 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. Social Media JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Social Influences on HealthThe 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 JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Culture as a Social Influence Cultural factorsDifferences 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Culture as a Social Influence Culture 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.  JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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Maria JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Biomedical Model Reason for visit: Maria complains of chest pain. Presentation: What kind of questions would the clinician ask? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Biomedical ModelPresentation: The focus is on physical causes of disease. The clinician will ask few questions on recent diet, pain history, and familial incidence.Possible Diagnosis:

Biomedical ModelPossible Diagnosis: Heart attack. 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. Recommendations: The clinician would refer Maria to a doctor to prescribe a medicinal plan for the patient based on biological etiology and pathogenesis. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Mental Status Exam JP Counseling & Associates, LLC Healing for Adults, Youth and Families

What is the Mental Status Examination (MSE)? May be viewed as the psychological equivalent of the physical examA 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Major Components of the MSE AppearanceMotor activitySpeechAffectThought contentThought processPerceptionIntellectInsight JP Counseling & Associates, LLCHealing for Adults, Youth and Families

George JP Counseling & Associates, LLC Healing for Adults, Youth and Families

MSE A 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Biopsychosocial model Possible Diagnosis:JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Biopsychosocial model Possible Diagnosis: Mild dementia and major depression. Recommendations:JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Biopsychosocial modelRecommendations: Cognitive functioning improved with antidepressants.

MSE 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Jane JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Jane A 27-year-old woman presented to the psychiatric emergency department with somewhat grandiose behavior, pressured speech, irritability, and psychomotor agitation. Possible Diagnosis: JP Counseling & Associates, LLCHealing for Adults, Youth and Families

JanePossible Diagnosis: 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.

key factors impacting the MSE Physical, social, cultural, and educational background. IntelligencePrimary languageAge JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Administering MSE Memory 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Administering MSELanguage 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Does the MSE Establish Competence? No. Competence relates to one’s ability to make reasonable decisions for themselves and others, such as 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Does the MSE Establish Competence?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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Mental Status Exam Mini Mental Status ExamJP Counseling & Associates, LLC Healing for Adults, Youth and Families

Screening JP Counseling & Associates, LLC Healing for Adults, Youth and Families

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 complicatedJP Counseling & Associates, LLCHealing for Adults, Youth and Families

Screening & Assessment for ALL Disorders is Necessary Because... Treating one disorder does NOT lead to effective management of the other(s) Treatment outcomes are poorer when co-occurring disorders are present.

Know Your Limitations…. Generally 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 Counseling & Associates, LLC Healing for Adults, Youth and Families

Screening 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? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

ScreeningThe 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.

Specific Screening Areas SuicidalityTraumaViolenceAddictionMental Health Disorders JP Counseling & Associates, LLCHealing for Adults, Youth and Families

IS PATH WARM I = IdeationS = Substance abuseP = PurposelessnessA = AnxietyT = TrappedH = HopelessnessW = WithdrawalA = AngerR = RecklessnessM = Mood changes JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Suicidality 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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 sexual 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 Counseling & Associates, LLC Healing 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? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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)? JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Assessment JP Counseling & Associates, LLC Healing for Adults, Youth and Families

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

Purposes of Basic Assessment Provides key information for treatment matching & treatment planningOffers 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 determination JP Counseling & Associates, LLC Healing 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 & Associates, LLC Healing for Adults, Youth and Families

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?How will outcomes be measured? What is the progress of the treatment plan and placement decision?JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Suicide/violence risk Clinicians are encouraged to think about violence risk in conditional terms If….thenThe conceptualization of violence risk as something that can change over time, across conditions, or in response to various interventions JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Suicide/violence riskThe 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) JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Key Questions in a Suicide/Violence  Risk Review With what? The means of suicide/violence under consideration Access to the means selected Where and when? Possible location and timing of a suicide/violence Degree of planning Possible anniversary phenomena JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Key Questions in a Suicide/Violence Risk ReviewWhen 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 method

Key Questions in a Suicide/Violence  Risk ReviewWho’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 Counseling & Associates, LLCHealing for Adults, Youth and Families

Beck’s Suicide Inventory JP Counseling & Associates, LLC Healing for Adults, Youth and Families

diagnosis

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

JP Counseling & Associates, LLCHealing for Adults, Youth and Families SallySally comes into you office under the influence of alcohol

sallyIt is reasonable to suspect 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 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, and reports a diagnosis of Substance Use Disorder (in remission at present). JP Counseling & Associates, LLC Healing for Adults, Youth and Families

BradyMoreover, 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 & Associates, LLCHealing for Adults, Youth and Families

JP Counseling & Associates, LLCHealing for Adults, Youth and Families ValerieValerie comes into your office and says she hears voices regardless of whether she is sober or not

valerieNo 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Oscar 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

OscarOscar 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.

Diagnosis Principle #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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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 & Associates, LLC Healing for Adults, Youth and Families

JP Counseling & Associates, LLCHealing for Adults, Youth and FamiliesDiagnosis 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 & Associates, LLCHealing for Adults, Youth and Families

JP Counseling & Associates, LLC Healing for Adults, Youth and Families

The Documentation of a Proper Initial Assessment 1) 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; JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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: JP Counseling & Associates, LLCHealing for Adults, Youth and Families

The Documentation of a Proper Initial Assessment a) Family historyb) Medical historyc) Psychiatric historyd) History of alcohol and other substance abusee) Child and adolescent developmental historyf) History of occupational training/skills and work historyg) History of interpersonal relationships JP Counseling & Associates, LLCHealing for Adults, Youth and Families

The Documentation of a Proper Initial Assessmenth) History of past and current social support systemsi) Juvenile and criminal justice historyj) History of sexual relationships or psychosexual problems k) History of religious affiliation and practices l) Spirituality (aside from religion) m) History of physical, emotional or sexual abuse or other victimization

Treatment Plans JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Treatment Plans Road map to follow in treatmentNo 2 road maps should be the same—everybody’s journey is differentMust be fluid JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans Develop a Problems ListMust be evidenced by signs and symptomsMust be measurable“as evidenced by” or “as indicated by” JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans Problem 3: Acute alcohol withdrawal As evidenced by: Significant 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans Develop Goals Brief clinical statement of the condition you expect to change in the patientMore than elimination of pathologyDirected toward patient learning new and more functional methods of coping JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans Instead of: The patient will stop negative self-talk. Use: The patient will develop and use positive self-talk. Use: The patient will develop a positive self-image. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans Examples of Goals The patient will learn the skills necessary to maintain a sober lifestyle. The patient will learn to express negative feelings to his or her spouse. The patient will develop a positive commitment to sobriety. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans The patient will develop a healthy diet and begin to gain weight.The patient will learn how to tolerate uncomfortable feelings without using chemicals. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans The patient will develop the ability to use anger appropriately. The patient will sleep comfortably on a regular basis. The patient will learn healthy communication skills JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment plansThe patient will learn to share positive feelings with others. The patient will develop the ability to ask for what he or she wants.

Treatment Plans Develop ObjectivesA specific skill that patient must acquire to achieve a goalMust be measurable JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans Goals usually can’t be seen; objective can been seen.Can you see the patient read about Step One in the Alcoholics Anonymous book? Can you see the patient understand the illness of addiction? Can you see the patient gain insight? Can you see the patient complete the Step One exercise? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans Can 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? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans Goal 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plans Develop InterventionsWhat you do to help the patient complete the objectiveMust be measurableAt least 1 intervention for every objective JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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: ____________________ JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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: ____________________ JP Counseling & Associates, LLCHealing for Adults, Youth and Families

JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Treatment Plan Updates JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Treatment Plan Updates Problem 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plan Updates Problem 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plan Updates Problem 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plan Updates Problem 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plan Updates Problem 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Treatment Plan Updates Problem 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress Notes JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Progress Notes Legal and ethical standards clearly state that therapists must maintain some kind of record of the treatment they provideThe Documentation Function of Progress NotesBrief, 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.  JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress Notes The 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress Notes Good 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. Thorough 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). JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress Notes Content, 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. Progress 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Documenting Treatment Necessity Standards of third partiesTherapists 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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 and a direct service provider or team of providers. This principle implies that the two individuals work together to solve problems, achieve goals, and overcome barriers to goals. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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, & 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

4 Types of Contacts Engagement & treatment planningThis is usually the first activity that occurs between a direct service provider and consumer/client. 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. Many crisis events are actually predictable events that were not addressed in the treatment planning process. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

4 Types of ContactsExample: A relapse of alcohol or other drugs for an individual who recently completed addiction treatment is not unexpected. 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 Contacts Closure 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress notes 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress Notes Application 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). JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress notes 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress notes 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 provided3) 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); JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress notes 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; JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress notes 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; JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Progress notes 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). JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Documenting Progress of Treatment Evaluating 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Documenting Progress of Treatment 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). JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Documenting Progress of Treatment 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). JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Common Errors in Progress Notes Recording 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). JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Common Errors in Progress Notes Recording 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Common Errors in Progress Notes Recording 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Common Errors in Progress Notes Recording 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Common Errors in Progress Notes Writing an extensive note that correlates with the amount of time spent with clients. 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). JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. 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. 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Common Errors in Progress Notes Satisfaction: 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Common Errors in Progress Notes Addiction 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Impression & Plan Should be NEW and UPDATED in every note 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Do’s & Don’ts of Progress Notes  DO 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 …” JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Do’s & Don’ts of Progress Notes  DO 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 …” JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Do’s & Don’ts of Progress NotesBy 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 DO 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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 …” JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Do’s & Don’ts of Progress NotesInstead, 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 DO 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.” JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Do’s & Don’ts of Progress NotesIf 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 Notes DO write 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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. 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. JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Discharge Summaries JP Counseling & Associates, LLC Healing for Adults, Youth and Families

Elements of an Appropriate Interval or Closing/Termination Summary An 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. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Elements of an Appropriate Interval or Closing/Termination Summary The documentation of a proper interval or closing/termination summary, includes: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; JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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; JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Elements of an Appropriate Interval or Closing/Termination Summary4) 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); JP Counseling & Associates, LLCHealing for Adults, Youth and Families

Elements of an Appropriate Interval or Closing/Termination Summary6) 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 recommendationsJP Counseling & Associates, LLC Healing for Adults, Youth and Families

Elements of an Appropriate Interval or Closing/Termination Summary8) 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 JP Counseling & Associates, LLCHealing for Adults, Youth and Families