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