Author: Leaman Ralph

Welcome to the Addiction Counselor Exam Review. This presentation is part of the Addiction Counselor certification training. Go to http://www.ALLCEUs.com/certificate-tracks to learn more about our specialty certificates starting at 149 dollars Hi everybody and welcome to this presentation of Documentation Principles and what you're supposed to do in documentation. Over the course of the next hour or a little bit more yeah buckle in guys it's going to be a while we're going to discuss the elements of good documentation we're going to talk about different types of documentation that you need to know how to do this is not a instructional manual or presentation on how to write good treatment plans or good progress notes this is really hitting the highlights so if you hit or you get to a place where you hear about a type of documentation you don't feel comfortable with especially treatment planning from what I've been told on the current certification exams treatment planning plays a big role so you want to make sure that you know how to identify effective interventions but that's a different class today we're just going to hit the highlights of what you need to know about documentation so documenting the treatment process the client record is the most important tool to ensure continuity of care that's going to help every person on the treatment team collaborate and coordinate that's going to help you track progress remember what you did last week and what you're doing in the future you know what your goals are it's going to help the client visualize what's going to happen so documentation is really important and remember if it doesn't get documented it didn't happen and that's true in terms of billable services you know don't not document something because you make a mistake because that'll still come back to bite you but in terms of reimbursement and you know showing that you did what any good therapist would do in order to prevent liability document document document it's your best friend there are ways to shorten documentation there are a lot of times that you can use check sheets and things create check sheets in private practice to make it a little bit easier for yourself but it is important to have that documentation documentation contributes to service delivery by reducing the replication of services so if I look and I see that jimbob's already been referred to a psychiatrist well then I don't need to make a referral for Jim Bob to a psychiatrist if I look and I see that he's already interacting with workforce development services then I don't need to refer him there because it's already been done so it saves some effort on everybody's part it presents a cohesive longitudinal record of clinically meaningful information which is gibberish for saying you can see the clients progress you can see what's worked you can see what hasn't worked you can see incremental changes and more importantly sometimes the client can see incremental changes so they can look back you know six weeks and at what you were talking about back then and how they were presenting and how they were feeling and then look at today and you can compare and contrast so they can see that yeah everything may not be coming up roses but there has been a significant improvement documentation helps ensure reimbursement for services you don't ever want to say is going to ensure because the people who are reimbursing have the right to not reimburse you know they can deny claims so but you know you're not going to get paid if you don't document so you have to document in order to have any hope of reimbursement and good documentation will reduce the number of denials that you get and it assists in guarding against malpractice because you're documenting what was done by whom and if they were adequately credentialed you know if you're referring somebody for a nutritional assessment to a dietitian a registered dietitian you're going to note that in the record if you are providing nutritional assessment and information yourself you're probably not a registered dietitian which means you're not adequately credentialed so you know you could see the difference but you're showing that you're referring to other professionals and you're taking adequate precautions in the event that somebody's in crisis or you know needs some other sorts of assistance clinical documentation records professional services you do an intake we all know what intakes are differential diagnosis it shows how you arrived at your conclusion that this person has substance induced depression or or whatever you're going to show how you ruled out some of the medical conditions you're going to show how you ruled out underlying mental health pathology placement criteria are used in decision making so you have the a Sam generally sometimes it's the locus and you can use that to show you know the powers-that-be if anybody ever comes and look at looks at the record why you made the recommendation for residential or outpatient or or whatever recommendation you made you can show your clinical justification by the patient placement criteria which is really awesome now sometimes the client is gonna say no you know you're recommending residential but I'm not willing to do that and you're gonna document that in the chart what your recommendation is and what the client chooses to do because they do have the ability to choose but again you know you're showing that you made a good honest effort to put them in what appears to be the best placement it documents treatment and other services provided so we can see what's going on if I'm looking at a record and of somebody and I'm hearing that they're on medications but I have no record of any sort of a doctor and you know I've read assessments before and it just drives me batty where they talk about a client being on antidepressants for example but then the client never gets any sort of mental health diagnosis and I'm like well what are they on the meds for if the doc is prescribing meds the doc clearly thinks that they have some sort of mental health issue so you want to identify what's going on what services you're providing what refer you're making the response to any interventions think about it this way you know if that client comes back for another episode of care and we know in recovery oriented systems of care that treatment is episodic and you may not be there the next time JimBob comes back but the next therapist can go back and review the record and figure out what's worked what didn't where the kind of where you left off and build upon that instead of having to recreate the wheel which saves a lot of frustration a lot of time and it enhances client engagement if they feel like they can go in and kind of hit the ground running instead of having to you know start back at square one it identifies referral services and the outcome not all referrals are going to go swimmingly but generally they do and you want a document that you're attending to the clients biopsychosocial needs if they need housing you're referring to the appropriate agency that can help them get housing if they need you know food stamps you're referring to the appropriate agency where they can get that there's a little bit of case management sort of stuff going on here because a lot of times you don't have a case manager but it's important because a client who is homeless hungry in pain and sick is not going to do really well on dealing with their depression or their self-esteem because they're not getting their basic needs met so you want to show that you're you know taking everything into account it shows the clinical course the record can help you identify and look back retrospectively and see you know what things may trigger an episode what things may trigger a relapse what things tend to mitigate it and help it you know not become so severe what sorts of interventions worked and looking at the course you can see when it started and whether it's continuing to get worse or whether it's starting to get a little bit better and instead of having long relapse periods you have shorter episodes maybe of lapses and it shows reassessment and treatment plan reviews people change you know as they get better that's awesome they're changing and the treatment plan will need to be updated to reflect their current needs and wants we want to do reassessments at least every 90 days but preferably every 30 days a lot of insurance companies and if you look at the level of care guidelines it's really important because they can deny payment if you're not doing a treatment plan review every single week for people who are in intensive outpatient partial hospitalization or residential that's not true of every insurance provider but it is true of a lot of them so you need to know how frequently you need to do these things in order to prevent denial of payment records compliance with state accreditation and payer requirements so you know clinical documentation helps you you know document exactly what's going on in Florida for example the state tells you certain services that have to be provided at the IOP level and at the residential level and you need to be able to document that if you're getting state funding you need to be able to document certain things if you're accredited by Jayco are you're gonna have to be able to show in the record that your treatment is you know in line with their guidelines you know they're going to look around at what's going on now but they also want to look at the charts to see you know how you actually follow through an entire course of care and it helps you maintain payer compliance I can't state this enough and we are in it to help people don't get me wrong and I hate to harp on dumb reimbursement however if you don't get reimbursed you don't keep your doors open so it's important to know what each payor requires in terms of you know how quickly does the intake need to be done how quickly does the treatment plan need to be done some payers say three days some payers say a week how frequently does the treatment plan need to be updated does the person have to see a psychiatrist within a certain period of time for your high levels of care the answer is yes so all this stuff is in what's called the level of care guidelines and each independent insurance provider has their own level of care guidelines so my recommendation and what I do in my practice is identify all of the providers that I accept and then I take the most stringent requirements for everything from all the different providers so I'm going above and beyond for some but I'm at least meaning every single providers minimum requirements and it takes a little while to do the crosswalk but it is well worth it because it helps you have a clinical record that applies whether it's Blue Cross and Blue Shield or Aetna or United or you know whomever documentation eases the transition to other programs and to referral sources if you call up a referral source and say you know maybe you're working with a client who has trauma issues and you're referring to an EMDR therapist and you call them up and say hey I got this person coming over and who's gonna need EMDR services sending them your way well that doesn't give them anything to work on so instead of again having them rip open that wound and go through you know a bunch of stuff that they've already talked about with you that was painful and distressing the clinical record can help ease that transition so the receiving therapist the EMDR therapist can review it and kind of know what they're dealing with and then start a little bit ahead of the game and it prevents duplication of information gathering when possible you know everybody seems to have to get demographic information well if there's a centralized clinical record that has the demographic information then everybody can add to that instead of having to get the same demographic information from clients every single time it facilitates quality assurance it documents the appropriateness clinical necessity and effectiveness of treatment when you are writing your integrated summary you are going to identify things in the intake that you did that support your diagnosis and support your intervention so you're gonna identify I'm doing this because in order to meet this need we're going to use this intervention so it identifies the clinical necessity you'll talk about appropriateness and that's in terms of diagnosis that's in terms of treatment setting and that's also in terms of age and culture so you're gonna if you use different interventions maybe use cognitive behavioral for some things and you use experiential for something else or maybe you refer to IOP for one thing for one client and you refer another client to outpatient or residential the appropriateness can be defended with your integrated summary and your patient placement criteria and then the effectiveness of treatment is going to be seen in your progress notes and your reassessments so you're going to be identifying okay we accomplish this goal accomplished that goal accomplished the next goal and you're gonna hopefully be marking them off and if you're not marking them off you're you're going to have addendums where you did you know an adjustment to the treatment plan in order to help the client start making progress towards that sometimes you're gonna scrap a goal because something else comes up that's more important I worked with one client who was just an amazing woman but she found out when she was in treatment with us that she had breast cancer well you know getting housing and getting a job those kind of goals kind of went out the door when that came up and the one of the main focuses of treatment for awhile became remaining clean and sober managing her anxiety and managing her feelings and you know recovery from the breast cancer and she went into significant chemotherapy and we were blessed enough to be able to keep her on our unit while she was going through chemo because she didn't have any family but you can see how sometimes you know there's a great treatment plan but then life happens and you got a drop back in punt and the treatment plan is going to show and the reassessment is going to show why you changed gears or changed directions so nobody goes well what in the world happened there you know I thought she was gonna discharge and then three months later she's still on the unit what's going on well you know we can we were able to justify why that was important it substantiates the need for further assessment and testing if you have a client who comes in who may have fetal alcohol spectrum issues you know because we know that alcoholism runs in families it's not uncommon for clients to have a mother who was an alcoholic now you know I'm not saying that every mother's an alcoholic and every person who has an addiction has a parent a mother who's an alcoholic but I'm saying the likelihood is higher if you're working with somebody with an addiction that their mother and for fetal alcohol spectrum disorders this has to be the mother because it's taint damage to the fetus that's done in utero so you know dad doesn't have anything to do with that so if you think the person has FASD or an F ASD you can refer because you need to get neurocognitive testing and all kinds of other things done but that will help them get set up for higher level services and reimbursement on multiple levels through SSI potentially if they have significant impairment its documentation supports termination or transfer of services if they've reached maximal gains at this level of care it's going to show or and kind of along the same thing if something happens and they can't participate in this level of care right now they need to be transferred to a crisis stabilization unit documentation will show why they were discharged from one place and sent to another it identifies problems with service delivery by providing data to support corrective actions when I worked at the facility I worked out we had multiple programs we had case management and outpatient residential and detox and crisis stabilization and yada yada yada and sometimes there would be too cooks in the kitchen so referrals wouldn't go off as planned or one person would think they were running the master treatment plan while another program would think they were running the master treatment plan and then reimbursement would get messed up so we were better able to figure out who was the single point of contact for this client and what the treatment plan was adding two methods to improve and assure quality of care so if we figure out that yeah this is working really well but you know we have this great intensive outpatient program but our aftercare program is really non-existent and it's it's imperative to have an aftercare program let's look at how we can do this in order to help people stay clean and sober it provides information that's used in policy development program planning and research another example that we used during the time that I was working at the at that clinic we realized that there was a need for a mother baby unit there wasn't one in our 13 County region so we wrote a grant and we created a unit that reached out to mothers who were still pregnant ideally didn't have to be but ideally still pregnant we helped them stay clean and sober until they delivered and then they stayed with us for another six months so we identified a gap in services you know because pregnant and postpartum women were really not getting a lot of services and we met that need and documentation provides data for use in planning professional development activities it helps you see what might be a need if you've suddenly got a lot of people coming in who have trauma issues then staff maybe need to be trained on trauma focused cognitive behavioral or cognitive processing therapy in order to better serve that particular population or you may have an influx of clients from a different culture you know right now in Florida there are a lot of people that have come into Florida from Puerto Rico after the hurricane so there's a need for services that are truly sensitive to people from Puerto Rico so it helps you identify who's coming through our doors what are their needs and what kind of training would benefit our staff so they can serve them more effectively and it fosters communication and collaboration between multidisciplinary team members a lot of times I would never see the doctor or the psychiatrist when they would come to see the clients that were on residential but I knew that they were reading my notes and they knew I was reading their notes because we had to initial so it made sure that all of the people in the team are at least communicating via the chart if not a team meeting unfortunately when you get into documentation you also get into big sticky issues with confidentiality and with substance abuse you need to be really aware of the Code of Federal Regulations 42 part 2 or CFR 42 part 2 and this handles the confidentiality of alcohol and drug abuse page patient records 42 CFR part 2 applies to all records relating to the identity diagnosis prognosis or treatment of any patient in a substance abuse program in the u.s.

So this is in addition to HIPAA and hi-tech and all of those substance abuse clients have additional protections there's a prohibition data that would identify a patient as suffering from a substance use disorder or as undergoing substance use disorder treatment you can't identify that information unless you have a specific release of information so if you're seeing somebody for mental health issues but they've also got you know a substance use disorder you can't divulge that that's separate information and their record is extra protected 42 CFR part 2 allows for disclosure where the state mandates child abuse and neglect recording sometimes the child abuse and neglect is directly related to the substance use or you're the only provider and you're in a substance abuse treatment program and you have to make a mandated report yeah it's allowed it allows for disclosure when cause of death is being reported so if you have a client in your program who dies and you have to report the cause of death you can disclose at that point or if the client passes away when they're on your on your facility and unfortunately it happens sometimes then you know obviously people are going to know where that person died because the everybody's going to come pick them up and do the investigation and you can disclose when there's an existence of a valid court order sometimes the courts will say this is important to know and that's varies by jurisdiction so in order to release information you have to have a written release and a written consent requires 10 elements and this is so important because so often I see releases of information that don't contain all ten elements number one do not ever have a client sign a blank release of information you know saying you know just in case we need it just sign it so I haven't know that's a big big big big no-no so anyway the release of information to be valid and if it's not valid then technically you can't release the information so it has to have all ten of these elements the names of the program's making the disclosure the name of the individual or organization that will receive the disclosure the name of the patient who is the subject of the disclosure you know that's all pretty standard the specific purpose or need for disclosure that gets a little bit you know why are you making this disclosure because the client requested it because of a court order in order to coordinate care what's the need a description of how much and what kind of information will be disclosed generally it's not everything you need a special release of information according to HIPAA in order to release progress notes as opposed to release other information so you know on ours we have we'll check boxes so you can identify whether its assessment attendance drug trip drug testing results etc you have to have a patient's right to revoke the consent in writing and the exceptions so there has to be a paragraph somewhere that lets the patient know that they have the right to revoke consent in writing you know at any time unless and there are a few exceptions but there they're few and far between and your legal department will handle that some agencies say clients can revoke consent verbally however the requirement is only that it has to be done in writing so if a client wants to revoke consent they need to write it down and give it to you showing that they want the consent revoked and then you know if they're there you cross through the the consent form you write void you date it you put your initials on it and they put their initials on it that's the ideal situation they can mail in a letter revoking consent as well you have to have the date or condition when the consent expires if not previously revoked now my program we always did a standard one year or 90 days depending on the program unless the client revoked consent however your program may be different or the client may choose the wind' the timeframe the signature of the patient and/or other authorized persons so if the patient is a minor or is not able to sign for themselves and they have an authorized representative you know you need those signatures your signature and the date on which the consent is signed so generally you have a witness there and you have the date that the witness and the person signed it so it has to have all ten of these things when used in the criminal justice setting expiration of the consent may be conditioned upon the completion or termination from a program so when Jim Bob gets released from jail this consent expires is can happen information can be shared within an agency on a need-to-know basis only with people on the treatment team only so it need to know you know if you're not on the treatment team then you don't need to know so we used to have this big medical records room and you would walk into it and there were literally thousands of files could I have pulled a file off the off-the-rack and looked at it and read it yeah I could have but that's not okay that is a violation of HIPAA as well as a bunch of others because I have no need to know about any random patient that is being seen so it's important to make sure that you've got good control over who can access records information sharing can be done with the release it can be done to the client you don't have to have a release to give the information to the client or under specific circumstances and that goes into confidentiality we'll talk about a little bit later agencies generally have policies for who is allowed to release information so the lady at the front desk probably can't release information it probably has to come from the therapist or from the risk manager clients have the right to review and amend their records if they request to view or amend the record is denied then we must provide a written explanation to the client so you know generally write your notes and write your everything assuming the client is going to read it use objective information don't be you know derogatory in any sort of way explain your findings and you know keep the client involved if they request to amend the record and and the agency denies it for some reason it says no you can't see your record or no you can't amend it there has to be a really really good reason we had some circumstances where the client wanted to amend the record and our executives decided that the amendment they were going to make was not didn't seem to really have a good grounding in reality the client was allowed to submit their amend in their handwriting and it was added to the case file and noted that this was a client amendment to the case file so your agency may handle it multiple ways but unless you provide them really good reason they have the right to review and amend the record now that doesn't mean take out something that you put in there because once something's in the record it's in the record henceforth and forevermore but they can add an addendum and so can you all right HIPAA and hi-tech these protect insurance coverage of workers when they're when they change or lose their job this is the idea what it was supposed to be for its safeguards the privacy of their information so if you're changing jobs or whatever you know nobody can really access your information to find out anything about you before they hire you etc it combats waste in healthcare delivery because it insures or hope hopefully ensures that we're communicating and the portability part of HIPAA means clients can take their record from one place to the other so you don't have to duplicate the intake and all a bunch of the other stuff necessarily and it simplifies administration of health insurance those were the that was the hope of HIPAA it kind of ballooned out of that so what do we need to know about HIPAA medical records are legal documents all states have policies regarding record retention medical records of adults are retained for seven years medical records of minors may be retained for longer so you need to know what your state requirements are agencies and solo practitioners should have policies identifying retention and storage policies so how long do you store it how do you store it how do you keep it safe who has access to it yada yada yada back to CFR 42 all records must remove patient identifying information and sanitize software printer ribbons FAQs hard drives and printer hard drives when you're talking about disposing of files you need to dispose of them in a way that removes patient identifying information and if you use hard copy still if you have software and this includes the hard drive in your copier a lot of people forget that one that has to be wiped and printer ribbons have to be destroyed fax hard drives have to be destroyed and printer hard drives have to be wiped and I guess wiping is really what we're calling it you don't have to actually physically destroy it but it has to be completely wiped don't just delete the file if you delete the file it goes in bits and pieces into your computer's never-never-land so to speak but people can put those pieces back together that's actually what my husband does for his you know career is find those pieces that have had been lost or somebody tried to delete something and he gets it back all client records and identifying information must be kept out of sight of unauthorized personnel well we know that so we keep our records behind to close to closed and locked doors okay that's great we have passwords in order to get into computer systems that's great but there are other things like lists and rosters you know sign-in sheets technically are supposed to be kept out of sight and people aren't supposed to be identifying information attendance records you don't want have want to have clients coming up and signing their own attendance record where they can see who and their groups been there for the past five days and who hasn't appointment schedules you don't want to be a client a client to be able to see what your schedule is for the week and who's coming in to see you computerized information must be on an encrypted hard drive full encryption of the whole hard drive not just that one folder client records need to be kept you know secure and phone messages you don't want to have the secretary sitting there with 17 phone messages across her desk while other people are coming in and checking in and then looking and going oh I didn't know Bob Jones was the client here so you need to make sure that phone messages are kept you know if they have the little message sheets keep them in a like a cigar box or a pencil box and then disseminate them to the therapists as appropriate therapists do the same thing don't have receipt books or phone messages just out where any client can see them if you discontinue your program you decide to close your practice or your practice gets bought by somebody else it must you must remove patient identifying information from your records or destroy your records including sanitizing any associated hard copies or electronic media to render the patient identifying information non retrievable in a manner consistent with the policies and procedures established under CFR 42 part 2 unless the patient gives written consent to transfer the records to the acquiring program so if somebody buys your program your your practice you have to keep those files for that 7 year period or whatever but and you're not going to transfer those unless you have written release from the client or if there's a legal requirement that records be kept for a period specified by law which doesn't expire until after the discontinuation or acquisition of the program so again if you haven't met your 7-year requirement that's generally a legal requirement you still have to hold on to those records but you're not going to pass them on and definitely not pass them on with patient identifying information to the new program unless you have a written release records which are paper must be sealed in envelopes or other containers and labeled as follows records of insert name of program required to be maintained under insert the statute or regulation until a date no later than insert the appropriate date so basically it says I have to hold on everything in this box or in this envelope that is sealed until XYZ date and time at which time it will be destroyed all hardcopy media from which the paper records were produced also need to be sanitized in order to render the data non retrievable records which are electronic must be transferred to a portable electronic device with implemented encryption so a hard drive that has that is encrypted so there's a low probability of assigning meaning without the use of confidential processes or key so you know what's on that hard drive it's encrypted so nobody else can access it even if you know they were to put it into a computer but you still have the client information there the electronic records must be transferred along with a backup copy to separate electronic media so that both records and the backup have implemented encryption so you don't want to just have one hard drive because hard drives can fail you need to have backups in order to say you're securely sir securely saving the data within one year of the discontinuation or acquisition of the program all electronic media on which the patient records or patient identifying information resided prior to being transferred must be sanitized so again you want to check with your legal department to see where the seven year rule falls but if it's outside of that seven year rule then definitely within a year after that the information needs to be destroyed portable electronic vise device or the original backup electronic media must be sealed in a container along with any equipment needed to read or access the information this is important because technology moves quickly and you know back when I started working on computers we had those you know five and a quarter floppy disks you can't find a computer now that can read those most computers don't even have CD drives in them anymore everything has to be on a thumb drive so you need to make sure that not only is the information there but it will be readable in the future and then there's a special thing records of this program required to be maintained under this legal authority until a date not later than duh so you want to label everything so you know what it is when it's to be destroyed okay so many agencies govern the content scope and quality of documentation the single state authority or SSA in your state has state service and licensing rules so it's important to communicate with your SSA and that's generally also the agency that does your licensing so when you get licensed as an independent provider you'll know what the regulations are the SSA may set forth time frames for documentation completion and who needs to sign and credential the documents so if you're a registered intern or you're not certified yet who has to co-sign on your documentation accreditation bodies also put their two cents in about documentation and they addressed quality from an organizational leadership and client care perspective so generally accreditation bodies are looking at quality of care and quality of documentation so good quality documentation will hopefully show good quality care many agencies govern the content scope and quality of documentation including third-party payers who set the guidelines through their level of care guidelines and other provider agencies so if you are when I worked with the Department of Corrections for example they had certain very specific requirements for the documentation of my clients so what types of documentation are there there's lots screening is the first type of documentation and good screening identifies the referral source the presenting problems background biopsychosocial information and this isn't going to be an in-depth everything but it's going to get a general idea about what's going on so we can rule out or rule in physical issues social relationship interpersonal issues as well as psychological issues is going to note the person's emotional and mental status at that time it will note their strengths and preferences for treatment for recovery for interventions and it will make a recommendation for assessment or other referral as needed so sometimes screenings just happen like it workplace affairs the screening happens and it's like yep you seem to be fine no further action needed by the bank and that chart is closed for others you may determine that the person may need a physical to rule out you know things like hyperthyroid that may be causing symptoms that look like hypomanic symptoms or look like stimulant intoxication you may need to refer to detox you may there are a lot of referrals that may need to be made but a screening is not a diagnostic interview it's when you identify whether there's a likelihood that the person may have a problem that needs further assessment intervention documentation so intervention is like your entry level services intervention documentation includes client identifying information the source of the referral client placement information you know why were they put into your program when were they put in how long are they going to be there the screening information that got them to that point informed consent for services including any drug testing that may be required and drug testing has its own form that needs to be signed dated credentialed by the client and counselor and witnessed and if you've done drug tests you know all this but it's important to get that informed consent for intervention services there's a release of information that has all the ten necessary components as needed so if you need to talk to a referral source get a release of information signed the intervention plan which is a lot broader or whatever you want to say than a treatment plan is signed dated and credentialed by the client and counselor and witness so you know you know this with your documentation you've probably done this already you know with intakes and everything else the client signs it you sign it you both date it and you have to make sure your credentials are on it if you're not already certified or licensed then you have to have somebody who is certified or licensed cosign on it most of the time intervention documentation also includes copies of correspondence or reports with referral sources and a transfer or discharge summary at the end of the intervention service administrative documentation in general this is going to be the stuff that's used for billing it's not the clinical it needs to be accurate concise include recommendations referrals case consultations legal reports family sessions and discharge summaries what you're like well that's kind of clinical isn't it a little bit but in order to get reimbursed the administrative side of things we have to have good documentation in all of those areas administrative documentation is conducted at admission and specified intervals throughout care so your administrative documentation is going to be a reassessment it's going to be your treatment plan updates it's going to be all of those things so types of administrative documentation your client identifying and demographic information referral source name and address financial information assigned client rights document assigned informed consent for treatment document any releases of information that you need assigned orientation to the program indicating that the client did receive orientation outcome measures that help identify whether your program is being successful and when you know when JimBob meets these criteria he or she is going to be ready for discharge and client placement information that goes back to your a sam or your locus medical documentation which is often in another section of the file includes the medical history the nursing assessment the physical exam the lab tests which almost always have to include a TB and pre-admission physical records of medical prescriptions and changes in medications that occurred you know what prescriptions were the person on when they got there and what what did they take while they were in your program even if you're not residential you need to know what meds they're on and any changes that their doc may make or your doc and what are they discharged with your medication administration records so if you're in residential then the client is probably going to or may receive medication while he or she is there so the medication administration records need to become part of the chart to show you know when Jim Bob took his medication who administered it and yadda-yadda and nursing notes so any notes that your staff nurse makes regarding the client's progress now clinical documentation is the stuff that we enjoy doing screening assessment treatment planning progress notes and your discharge summary so we're going to get into those in the in a few minutes I do want to mention electronic health records really quickly because you know you have all this administrative medical and clinical documentation a lot of times now it's going into an electronic health record health information technology is the secure management of health information on computerized systems it helps track data over time track progress of those who leave treatment and monitor quality care within practice just like documentation does but when it's on a computer it's a whole lot easier to run a program and get pretty little charts spit out behavioral health lags in adoption of these electronic health records because of cost technical limitations you know there's a lot of different players who want different things so creating a standardized electronic health record for behavioral health has been really difficult lack of standardization of data elements lack of interoperability of systems between you know doctors and therapists and whatever you know you have to have if your doctor has a system made by X Y Z and you have a system made by Acme they still have to be able to talk it's kind of like getting an apple or a Mac computer and a Windows computer to talk doesn't always happen so we need to make sure that the different electronic health records out there can communicate with one another attitudinal constraints we don't like change an organizational lack of expertise in health information technology management most programs don't have a technology director especially smaller programs so integrating this is really overwhelming and it can be really costly if everybody has to have a computer in order to put in there their client information general elements of clinical documentation whether it's administrative clinical or medical must be clear concise accurate written in ink time stamped or dated so you have to have all that information in there if you write I've had some staff members their handwriting was atrocious you could not read their notes or their assessments to save their life that is not good clinical documentation because it doesn't help anybody documentation is an ongoing responsibility for all professionals and should be completed as soon as possible after the contact don't wait until Friday to do all your notes for the week ethically you need to do it as soon as possible and I'll give you a little hint when I do groups oftentimes I will have a sheet that I pass out at the end of group has the client identify three things they got out of group and then you know a couple other questions about you know how they're feeling if they feel like they need a treatment plan reassessment and just a few other things to give me information then I have something in the clients handwriting to put in the chart but I also have the brunt of the progress note kind of done already and if you use soap notes or DAP notes you can kind of put that on there and have the client fill out what they think they would put for their notes that's helpful in group for individual individual sessions are generally supposed to be 45 to 50 minutes so I end right about 45 minutes maybe a little longer tend to run late and the client and I create the progress note together that way they review what we talked about they review the progress they've made they review what they're supposed to be doing in the upcoming week and they know what's going in the chart so it's not mystical and magical you know they are an active participant and I have the note done before the end of the hour so it's kind of a win-win-win all around okay documentation of sure's accountability the responsibility for accurately representing the client situation rests with the counselor and the clinical record not the client so like I'm saying we can get all of this input from the client but making sure that it's accurate when we put it in there and you know pulling it all together is incumbent upon us good clinical documentation spares the client from repeating painful details so we're not going to have them you know if you're talking with a client about a trauma situation you're gonna put enough in your clinical record that you don't have to have them remind you you know remind me again about what happened when your house burned down or what no that's rude um so you want to have enough documentation that gives you an overview or the next counselor sort of an overview of what happened and then if they need to delve into details later they can language language must be objective but descriptive so if you're saying that the client is decompensating well that doesn't tell me anything in what way as evidenced by you know the client is I diagnosed with the client with depression because they have these symptoms as evidenced by that is your best friend phrase as evidenced by documentation must identify persons places direct quotations and sources of information so if the client says you know I'm really feeling off my game you can put that in there so we know kind of where the clients coming from we want to use direct quotes from collateral sources that we get and identify who gave us this information clinical documentation is a legal record and the clinicians signature and credentialing indicates the truthfulness of it so if you sign it then it happened the treatment plan good treatment plans are hard to come by they're really easy to write if you don't overthink it but I find that most people overthink it so there's a hole that's actually a couple of classes on treatment planning because it is so important not only to guide treatment but to help clients learn how to set goals and achieve them treatment plans are a contract between the client counselor and treatment team each being responsible for its development and implementation the clinician needs to recognize that treatment occurs in different settings over time so you know treatment may be happening but you know counseling is only part of what going on there also in maybe case management or vocational rehabilitation or you know so treatment occurs medical in different settings and we need to be able to integrate all that into the treatment plan much of the recovery process occurs outside of or immediately following formal treatment when people do their homework assignments and they have their aha moments when they generalize their progress when they create that support system on the outside treatment is often divided into phases engagement stabilization primary treatment and continuing care treatment planning plots out a roadmap for the treatment process treatment plans are completed once a diagnosis is made a level of care is determined and the client is admitted to the program now after the initial assessment there's usually an initial treatment plan done but the real treatment plan generally needs to be completed within three to five days after admission once the clinician has finished the assessment paperwork and everything level of care is determined based on diagnosis and the clients strengths and assets so if you're familiar with the a Sam for example recovery environment is one of those dimensions that we look at and if they've got a really strong recovery environment then the option may be or decision may be made to refer the person to eiope instead of residential whereas if they have a really poor recovery environment then we may opt to refer the person to residential so they have a better chance in the first 30 to 60 days of you know getting a handle on things treatment plans address all biopsychosocial needs not just mental health they establish what changes are expected through achievable goals clarifies what interventions and counseling methods will be used to help the patient achieve those goals sets the measures that will be used to gauge success and that's where we go with as evidenced by again so if the client says you know instead of saying I'm going to quit using drugs they may say I'm going to develop a healthier life so how do we know when the client has developed what he or she defines as a healthier lifestyle well as evidenced by I'm going to develop a healthier lifestyle as evidenced by getting eight to nine hours of sleep a night eating a relatively nutritious diet as decided upon but between myself and the dietitian developing healthy support systems yada yada you see what I'm getting at so you're going to be able to go through and anybody would be able to go through and Mark off and say either yes or no achieved it achieved it achieved it achieve the goal so it's kind of a yes or no thing treatment planning incorporates the clients strengths needs abilities and preferences and I'm big on this you all probably know that if you took our addiction counselor certification training course temperament is huge extroverts and introverts have different needs judgers and perceivers have different needs auditory and visual learners have different needs and people in general based on their culture and just their cognitive aptitudes are going to have different strengths and needs so we want to form the treatment plan around the clients strengths and build off what's already there what already works referrals are made to other agencies as needed when referrals are made collaboration is essential to keep clients from falling through the cracks so treatment planning is going to identify you know client will get enrolled for Medicaid well you're probably not going to do that so you're going to identify who the client is going to see at whatever office they've got to go to in order to get enrolled in Medicaid but that's going to be part of the treatment plan treatment planning information even within the agency is restricted to need-to-know and treatment plans may have to be co-signed by a clinician who is already certified or licensed the function of the treatment plan well treatment planning is an action-oriented process that lays out logical goal directed strategies for making positive changes just like if you're going to make lasagna from scratch and you're gonna follow a recipe same sort of thing here and based on your preferences you know when I make my marinara sauce I use roma tomatoes that is my preference I know other people who use different kinds of tomatoes so different preferences I know that I want to do it in a shorter period of time so I'm not going to make the the noodles from scratch that's a need that I have because I don't have the time to make noodles from scratch so my recipe is going to be slightly different than my stepfather's recipe but that's okay and treatment planning is the same way just think of it very very simplistically like a recipe don't get too overwhelmed and tried trying to make it too complex because clients aren't going to be able to make complex treatment plans and treatment planning establishes a collaboration between you and the client so you can mutually prioritize agreeable goals you figure out what do you want I've worked with clients who were involuntary and you know they didn't really want to quit using however they were on probation and they wanted to get off probation well I wanted them to get off probation but I wanted him to quit using in order to get off probation they had to be clean during the time they were in treatment so that became our goal because that was mutually agreeable you know it's like well your goal is to get off probation in order to do that you got to stay clean so let's work together to make that happen during the next 16 weeks and generally it worked that way achievable goals are selected by assessing and prioritizing client needs and taking into account their level of impairment if you've got a client who is significantly impaired they've got major clinical depression they're detoxing from five years of stimulant abuse they're not going to be going out and getting a job next week that's you know well down the road so the goals we're looking at now are more like stabilization and engagement you want to take into account motivation what does the client want to achieve because they're not going to be real motivated to achieve what you want to achieve unless they want to get out they want to get discharged from the program successfully and in order to do that they've got to meet your goals but ideally help them identify goals that are meaningful to them and you're going to look at the real world influences on needs so if they're going to be discharged in 30 days even though they may not be quite ready to start looking for housing if they need to have housing when they get out in 30 days then that's probably going to be a high priority treatment plan goal because you don't want them being discharged to the street treatment plants consider client needs readiness preferences and prior treatment history looking at what did and didn't work because there's no sense repeating something that you've done four times that hasn't worked yet we're going to look at their personal goals and then we'll look at obstacles like transportation and childcare and those sorts of things that might preclude someone from going into residential or make it difficult for them to get the evening IOP for example treatment plans have SMART goals specific measurable achievable realistic and time limited these goals are broken down into smaller objectives so you know think about it like you want to climb a staircase well that's great that's your goal you want to climb a staircase in the next 45 days wonderful you're gonna be taking a little while at each step but each step is an objective so your end goal is the top of the staircase what is the first thing you need to do to start moving towards the top of that staircase what's your first step all right once you get that done what's the next thing you got to do again think of the recipe first thing you've got to do is find the recipe then you've got to figure out what you've got on hand then you've got to figure out you know what you need from the store then you've got to go shopping you know one step at a time don't make it too complex treatment plans anticipate the type duration and frequency of services so you know a lot of times we may say if they're in IOP there's going to be three hours a day five days week for the first month and then once they accomplish certain goals then they can step down to three hours a day three days a week etc treatment plans identify who's responsible for what so if the client has to go do something it's going to be clearly indicated that the client needs to make the appointment with social services to get enrolled in programming versus the counselor will make the appointment for the client to go to Social Services you know whoever supposed to do it it needs to be noted and there has to be a timetable you know this needs to be accomplished by X date if it doesn't get accomplished by X date it's not the end of the world however you need to do a reassessment and go okay why didn't this happen what do we need to adjust it incorporates client input and participation in development it helps the client prioritize presenting issues so I mean they come in and generally there's a whole litany of stuff that they need to work on and it can feel really overwhelming but I liken it to a woven blanket for clients that woven blanket is over your head right now you can't breathe you can't see it's miserable it's hot any string you pull on is gonna start making air holes in that blanket and making it lighter and eventually you will unravel the whole blanket so let's figure out you know of the issues that you've got going on right now which are most you think are most important to work on and which are you most motivated to work on what string are you willing to pull first you get input from client on their goals and objectives so what is there as evidenced by look like you know if I am happier as opposed to being depressed what is that going to look like if I am healthier as opposed to unhealthy what is that going to look like how am I going to know when I'm living a healthier lifestyle and both the counselor and client sign the plan the clinician may also facilitate and manage referrals because oftentimes we don't have case management that we can rely on at minimum the plan is a flexible document that uses a stage match process to address identified substance use disorders so stage match process if you think back to the stages of readiness for change pre contemplation contemplation preparation action and maintenance each stage requires different interventions so that's tip 35 from Samsa if you need to refresh it looks at the recovery support environment it addresses potential potential mental health conditions you know based on readiness for change for that issue you know somebody may be in the action stage of readiness for change on their substance use but not you know ready to do a lot about their anxiety it's usually the opposite but whatever so you need to make sure that you stage match by issue because the person is not just going to be globally in the action stage of change there are going to be some things that they're not really that ready to work on yet you want to identify potential medical issues employment education spiritual issues social needs and legal needs and there are other things like childcare and other wraparound services that can go into this too but these are the big ones initial treatment plans are done an admission or within 24 hours based on information from the assessment and screening and serves as the initial roadmap they include presenting problems preliminary goals type frequency and duration of service and the signature and date of the client and counselor with counselor credentials so again this is the initial treatment plan as you get into treatment and start to know the client a little bit better you're going to formulate a more in-depth treatment plan this one has to be done either at admission or within 24 hours an individualized treatment plan has the problem and a problem description that answers the question why are you here that's the problem not the goal I'm here because I have a substance use disorder what's my goal to not have a substance use disorder it identifies the clients strengths you know we are going to build on strengths so client will build on his to stay clean and sober yada yada it has concrete measurable goals concrete means you can observe them you can see them you can either say yes it was done or no it wasn't not yeah it was probably accomplished it's yes or not the objectives are there so that big goal is broken down into those smaller steps it has strategies for achieving those smaller steps so you know if the first step is to start building a recovery support network well that's wonderful how are you going to do that strategies answer how you start going to a a meetings you know start going back to church call up your five closest friends that are healthy supports whatever the treatment plan includes the diagnosis usually that's up at the top the signature of the client and counselor and the signature of the clinical supervisor if required ongoing assessment and collaboration is used to regularly regularly review the treatment plan and make necessary modifications many IOP and residential programs have to review the treatment plan once a week with the client and get the client to sign off sometimes you get a 30-day reprieve but you need to know what your payers and your state requires review should be completed at minimum at major or key points in the client's treatment course including admission obviously you're going to develop it readmission you know maybe they discharged and they were out for three months and then they relapsed and they're back well you may be able to look at their treatment plan and see where they're supposed to be because they were in an IO P program and work with that but you're gonna need to reassess it at readmission at transfer at discharge if there's a major change in their condition such as you know they'd have a manic episode or they're admitted to the crisis stabilization unit for suicidal ideation you're gonna do a reassessment and after 12 months regardless of what's going on after 12 months progress notes document the clients progress in relationship treatment plan goals and objectives each progress note should have the problem name and number because most clients will have like three treatment plan problems and then multiple like say eight objectives underneath it so maybe substance abuse recovery is the first treatment plan problem okay so that's problem number one and goal number a if you will the first goal is to start developing a recovery support system so in the treatment plan if I talk with the client about developing that recovery support system then I'm going to identify that we talked about problem 1a and what we what we addressed the progress note identifies what the client says and does generally I mean you're not going to do it verbatim it puts in counselor observations and assessments if the client seems to be doing really well as evidenced by and the clients observations and assessments I always put those in there too how do they think they're doing and what's their evidence as evidenced by and continued plans to address the presenting problem you also may need to document any new information if they get into a new relationship get a new job breakup whatever that will go in the progress notes the format for most people is the soap format the first part is the specific objective information and the last part is the assessment the interpretations and the plan for how to proceed you want to document the clients progress progress notes are based on what the client says and it does what the clinician observes the clients attitude demeanor nonverbals you know how compliant they are with treatment the counselors knowledge and experience so counselors are going to be able to differentiate between a lapse and a relapse for example they're going to be able to differentially diagnose if the client starts presenting with some symptoms of depression for example the clinician is going to rule out the use of depressant substances they're going to rule out detoxification from stimulants they're going to rule out hopefully medical conditions and they may rule in mood disorders or something so differential diagnosis is important to look at the physical and other potential causes for symptoms and danger to self or others I encourage my staff at every single treatment meeting to identify whether the client had any suicidal or homicidal ideation espoused I mean if they said I'm suicidal or I wish I could end it all that needs to be documented and to identify if the client had future plans was oriented to place and time you know just a general Mini Mental Status exam at every contact is really good to protect you and even in group I mean you're looking at people and are they bright and are they oriented and are they talking about future things or they withdrawn and sad and tearful and talk about how you know there doesn't seem any point in being there well you know if you hear that you probably need to pull them aside and talk to them more in depth so you know get a some documentation that you had good contact with the client and you have a good kind of idea about the pulse of things progress notes are not a verbatim transcript but a cohesive summary so one page you know don't write a dissertation the discharge summary discharge planning begins at admission discharge planning begins at admission okay I know I said it twice because it's that important you see client Jim Bob and you know your things are going well but then client Jim Bob goes out and relapses and never comes back well he's discharged at that point you don't know when the client is going to discharge necessarily so if you begin discharge planning at admission which actually is required by most insurance companies then you have a plan and you and Jim Bob have made a plan for this is how you're going to progress these are the options and resources available to you so Jim Bob has something to work off of in case he never returns you want to summarize in your discharge summary the service is delivered you know the discharge summary is done when Jim Bob is actually discharging discharge planning begins at admission so the discharge summary summarizes any services you did deliver how well the client accomplished goals and objectives and any discharge recommendations including referrals continuing care etc the elements of the discharge plan include the referral source you know because this is going to go back to the referral source saying Jim Bob discharged this is the summary of what happened presenting problems and the reason for services treatment goals methods and outcomes outcomes generally pertain to the person's ability to attain recovery build resistance and work learn live and fully participate in the community of choice so discharge summary is basically a big summary of the entire treatment episode it's going to indicate the condition of the client at discharge your prognosis and you know that's a little subjective but we got to make it follow up recommendations including continuing care and the aftercare plan and the counselors signature date and credentials you want to include the reasons for discharge on the discharge summary but reasons for discharge can be varied treatment completion that's the idea they may lead leave AMA or against medical advice that's not so ideal but it happens treatment non-compliance they're just not getting with the program or they're showing up and they're under the influence or you know a variety of reasons that it's therapeutically indicated to discharge them or treatment was just incomplete you know again they left before treatment finished they just it wasn't some what treatment incomplete is a lot like AMA but those are the four main reasons for discharge identified for the review exam organization of documentation is gonna vary a little bit between each agency but each page has to have the clients name and some sort of identifying number all entries must be signed if you make an error in documentation you line through it once you don't scratch it out you line through it once initial it date it and write error above it notes of any sort should never be removed from a file if you have late entries or Corrections they're put in as a separate document and noted as an addendum to you know progress note from to one of 18 or whatever so clinical document character at documentation characteristics need to be written knowing that others will read it it needs to be objective you know stay away from vague terms like client is doing well if you use a vague term then explain it as evidenced by uses descriptive behavioral terms client is oriented to person place and time not client seems to be with it today you know you want to use descriptive behavioral kind of clinical terms it avoids jargon so you don't want to overuse clinical clinical terms and it keep it simple again remember the client may read this it's concise and it's positive you know these are the steps the client is making this is the progress the client is making yes the client has had a setback but hey he returned for treatment and you know we're picking up and figuring out what we did wrong you don't want to be doomsaying and talking about how the client is non-compliant and resistant and just doesn't seem to want to be here and you want to keep it as positive as possible focusing on the strengths and the progress and making lemonade whenever you your client gives you lemons all right well that was a lot that we covered and I know documentation is not the most interesting thing but that kind of hits the highlights of what you need to know for your addiction counselor certification exam if you need more training we have lots of training at all CEUs calm and we have a full addiction counselor certification track that is a little over 400 hours and of multimedia information and that's for one hundred and forty nine dollars alright thanks for participating today or listening today and I will talk to you again soon

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