{"id":150217,"date":"2023-01-17T06:18:45","date_gmt":"2023-01-17T11:18:45","guid":{"rendered":"https:\/\/effectsofanxiety.net\/?p=150217"},"modified":"2023-01-17T06:18:45","modified_gmt":"2023-01-17T11:18:45","slug":"documentation-review-addiction-counselor-exam","status":"publish","type":"post","link":"https:\/\/effectsofanxiety.net\/archives\/150217","title":{"rendered":"Documentation Review Addiction Counselor Exam"},"content":{"rendered":"<p><div class=\"jetpack-video-wrapper\"><iframe loading=\"lazy\" title=\"Documentation Review Addiction Counselor Exam\" width=\"660\" height=\"371\" src=\"https:\/\/www.youtube.com\/embed\/ZyqF-w-myg4?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe><\/div><\/p>      <br><p> Welcome to the Addiction Counselor Exam\nReview. This presentation is part of the Addiction Counselor certification\ntraining. Go to http:\/\/www.ALLCEUs.com\/certificate-tracks to learn more about\nour specialty certificates starting at 149 dollars Hi everybody and welcome to this\npresentation of Documentation Principles and what you&#39;re supposed to do in\ndocumentation. Over the course of the next hour or a little bit more yeah\nbuckle in guys it&#39;s going to be a while we&#39;re going to discuss the elements of\ngood documentation we&#39;re going to talk about different types of documentation\nthat you need to know how to do this is not a instructional manual or\npresentation on how to write good treatment plans or good progress notes\nthis is really hitting the highlights so if you hit or you get to a place where\nyou hear about a type of documentation you don&#39;t feel comfortable with\nespecially treatment planning from what I&#39;ve been told on the current\ncertification exams treatment planning plays a big role so you want to make\nsure that you know how to identify effective interventions but that&#39;s a\ndifferent class today we&#39;re just going to hit the highlights of what you need\nto know about documentation so documenting the treatment process the\nclient record is the most important tool to ensure continuity of care that&#39;s\ngoing to help every person on the treatment team collaborate and\ncoordinate that&#39;s going to help you track progress remember what you did\nlast week and what you&#39;re doing in the future you know what your goals are it&#39;s\ngoing to help the client visualize what&#39;s going to happen so documentation\nis really important and remember if it doesn&#39;t get documented it didn&#39;t happen\nand that&#39;s true in terms of billable services you know don&#39;t not document\nsomething because you make a mistake because that&#39;ll still come back to bite\nyou but in terms of reimbursement and you know showing that you did what any\ngood therapist would do in order to prevent liability document document\ndocument it&#39;s your best friend there are ways to shorten documentation there are\na lot of times that you can use check sheets and things create check sheets in\nprivate practice to make it a little bit easier for\nyourself but it is important to have that documentation documentation\ncontributes to service delivery by reducing the replication of services so\nif I look and I see that jimbob&#39;s already been referred to a psychiatrist\nwell then I don&#39;t need to make a referral for Jim Bob to a psychiatrist\nif I look and I see that he&#39;s already interacting with workforce development\nservices then I don&#39;t need to refer him there because it&#39;s already been done so\nit saves some effort on everybody&#39;s part it presents a cohesive longitudinal\nrecord of clinically meaningful information which is gibberish for\nsaying you can see the clients progress you can see what&#39;s worked you can see\nwhat hasn&#39;t worked you can see incremental changes and more importantly\nsometimes the client can see incremental changes so they can look back you know\nsix weeks and at what you were talking about back then and how they were\npresenting and how they were feeling and then look at today and you can compare\nand contrast so they can see that yeah everything may not be coming up roses\nbut there has been a significant improvement documentation helps ensure\nreimbursement for services you don&#39;t ever want to say is going to ensure\nbecause the people who are reimbursing have the right to not reimburse you know\nthey can deny claims so but you know you&#39;re not going to get paid if you\ndon&#39;t document so you have to document in order to have any hope of\nreimbursement and good documentation will reduce the number of denials that\nyou get and it assists in guarding against malpractice because you&#39;re\ndocumenting what was done by whom and if they were adequately credentialed you\nknow if you&#39;re referring somebody for a nutritional assessment to a dietitian a\nregistered dietitian you&#39;re going to note that in the record if you are\nproviding nutritional assessment and information yourself you&#39;re probably not\na registered dietitian which means you&#39;re not adequately credentialed so\nyou know you could see the difference but you&#39;re showing that you&#39;re referring\nto other professionals and you&#39;re taking adequate precautions in the event that\nsomebody&#39;s in crisis or you know needs some other sorts of assistance clinical\ndocumentation records professional services you do an intake we all know\nwhat intakes are differential diagnosis it shows how you arrived at your\nconclusion that this person has substance induced depression or or\nwhatever you&#39;re going to show how you ruled out some of the medical conditions\nyou&#39;re going to show how you ruled out underlying\nmental health pathology placement criteria are used in decision making so\nyou have the a Sam generally sometimes it&#39;s the locus and you can use that to\nshow you know the powers-that-be if anybody ever comes and look at looks\nat the record why you made the recommendation for residential or\noutpatient or or whatever recommendation you made you can show your clinical\njustification by the patient placement criteria which is really awesome now\nsometimes the client is gonna say no you know you&#39;re recommending residential but\nI&#39;m not willing to do that and you&#39;re gonna document that in the chart what\nyour recommendation is and what the client chooses to do because they do\nhave the ability to choose but again you know you&#39;re showing that you made a good\nhonest effort to put them in what appears to be the best placement it\ndocuments treatment and other services provided so we can see what&#39;s going on\nif I&#39;m looking at a record and of somebody and I&#39;m hearing that they&#39;re on\nmedications but I have no record of any sort of a doctor and you know I&#39;ve read\nassessments before and it just drives me batty where they talk about a client\nbeing on antidepressants for example but then the client never gets any sort of\nmental health diagnosis and I&#39;m like well what are they on the meds for if\nthe doc is prescribing meds the doc clearly thinks that they have some sort\nof mental health issue so you want to identify what&#39;s going on what services\nyou&#39;re providing what refer you&#39;re making the response to any\ninterventions think about it this way you know if that client comes back for\nanother episode of care and we know in recovery oriented systems of care that\ntreatment is episodic and you may not be there the next time JimBob comes back\nbut the next therapist can go back and review the record and figure out what&#39;s\nworked what didn&#39;t where the kind of where you left off and build upon that\ninstead of having to recreate the wheel which saves a lot of frustration a lot\nof time and it enhances client engagement if they feel like they can go\nin and kind of hit the ground running instead of having to you know start back\nat square one it identifies referral services and the outcome not all\nreferrals are going to go swimmingly but generally they do and you want a\ndocument that you&#39;re attending to the clients biopsychosocial needs if they\nneed housing you&#39;re referring to the appropriate agency that can help them\nget housing if they need you know food stamps you&#39;re referring to the\nappropriate agency where they can get that there&#39;s a little bit of case\nmanagement sort of stuff going on here because a lot of times you don&#39;t have a\ncase manager but it&#39;s important because a client who is homeless hungry in pain\nand sick is not going to do really well on dealing with their depression or\ntheir self-esteem because they&#39;re not getting their basic needs met so you\nwant to show that you&#39;re you know taking everything into account\nit shows the clinical course the record can help you identify and look back\nretrospectively and see you know what things may trigger an episode what\nthings may trigger a relapse what things tend to mitigate it and help it you know\nnot become so severe what sorts of interventions worked and looking at the\ncourse you can see when it started and whether it&#39;s continuing to get worse or\nwhether it&#39;s starting to get a little bit better and instead of having long\nrelapse periods you have shorter episodes maybe of lapses and it shows\nreassessment and treatment plan reviews people change you know as they get\nbetter that&#39;s awesome they&#39;re changing and the treatment plan will need to be\nupdated to reflect their current needs and wants we want to do reassessments at\nleast every 90 days but preferably every 30 days a lot of insurance companies and\nif you look at the level of care guidelines it&#39;s really important because\nthey can deny payment if you&#39;re not doing a treatment plan review every\nsingle week for people who are in intensive outpatient partial\nhospitalization or residential that&#39;s not true of every insurance provider but\nit is true of a lot of them so you need to know how frequently you need to do\nthese things in order to prevent denial of payment records compliance with state\naccreditation and payer requirements so you know clinical documentation helps\nyou you know document exactly what&#39;s going on in Florida for example the\nstate tells you certain services that have to be provided at the IOP level and\nat the residential level and you need to be able to document that if you&#39;re\ngetting state funding you need to be able to document certain things if\nyou&#39;re accredited by Jayco are you&#39;re gonna have to be able to show in the\nrecord that your treatment is you know in line with their guidelines you know\nthey&#39;re going to look around at what&#39;s going on now but they also want to look\nat the charts to see you know how you actually follow through an entire course\nof care and it helps you maintain payer compliance\nI can&#39;t state this enough and we are in it to help people don&#39;t get me wrong and\nI hate to harp on dumb reimbursement however if you don&#39;t get reimbursed you\ndon&#39;t keep your doors open so it&#39;s important to know what each payor\nrequires in terms of you know how quickly does the intake need to be done\nhow quickly does the treatment plan need to be done some payers say three days\nsome payers say a week how frequently does the treatment plan need to be\nupdated does the person have to see a psychiatrist within a certain period\nof time for your high levels of care the answer is yes so all this stuff is in\nwhat&#39;s called the level of care guidelines and each independent\ninsurance provider has their own level of care guidelines so my recommendation\nand what I do in my practice is identify all of the providers that I accept and\nthen I take the most stringent requirements for everything from all the\ndifferent providers so I&#39;m going above and beyond for some but I&#39;m at least\nmeaning every single providers minimum requirements and it takes a little while\nto do the crosswalk but it is well worth it because it helps you have a clinical\nrecord that applies whether it&#39;s Blue Cross and Blue Shield or Aetna or United\nor you know whomever documentation eases the transition to other programs and to\nreferral sources if you call up a referral source and say you know maybe\nyou&#39;re working with a client who has trauma issues and you&#39;re referring to an\nEMDR therapist and you call them up and say hey I got this person coming over\nand who&#39;s gonna need EMDR services sending them your way well that doesn&#39;t\ngive them anything to work on so instead of again having them rip open that wound\nand go through you know a bunch of stuff that they&#39;ve already talked about with\nyou that was painful and distressing the clinical record can help ease that\ntransition so the receiving therapist the EMDR therapist can review it and\nkind of know what they&#39;re dealing with and then start a little bit ahead of the\ngame and it prevents duplication of information gathering when possible you\nknow everybody seems to have to get demographic information well if there&#39;s\na centralized clinical record that has the demographic information then\neverybody can add to that instead of having to get the same demographic\ninformation from clients every single time it facilitates quality assurance it\ndocuments the appropriateness clinical necessity and effectiveness of treatment\nwhen you are writing your integrated summary\nyou are going to identify things in the intake that you did that support your\ndiagnosis and support your intervention so you&#39;re gonna identify I&#39;m doing this\nbecause in order to meet this need we&#39;re going to use this intervention so it\nidentifies the clinical necessity you&#39;ll talk about appropriateness and that&#39;s in\nterms of diagnosis that&#39;s in terms of treatment setting and that&#39;s also in\nterms of age and culture so you&#39;re gonna if you use different interventions maybe\nuse cognitive behavioral for some things and you use experiential for something\nelse or maybe you refer to IOP for one thing for one client and you refer\nanother client to outpatient or residential the appropriateness can be\ndefended with your integrated summary and your patient placement criteria and\nthen the effectiveness of treatment is going to be seen in your progress notes\nand your reassessments so you&#39;re going to be identifying okay we accomplish\nthis goal accomplished that goal accomplished the next goal and you&#39;re\ngonna hopefully be marking them off and if you&#39;re not marking them off you&#39;re\nyou&#39;re going to have addendums where you did you know an adjustment to the\ntreatment plan in order to help the client start making progress towards\nthat sometimes you&#39;re gonna scrap a goal because something else comes up that&#39;s\nmore important I worked with one client who was just an amazing woman but she\nfound out when she was in treatment with us that she had breast cancer well you\nknow getting housing and getting a job those kind of goals kind of went out the\ndoor when that came up and the one of the main focuses of treatment for awhile\nbecame remaining clean and sober managing her anxiety and managing her\nfeelings and you know recovery from the breast cancer and she went into\nsignificant chemotherapy and we were blessed enough to be able to keep her on\nour unit while she was going through chemo because she didn&#39;t have any family\nbut you can see how sometimes you know there&#39;s a great treatment plan but then\nlife happens and you got a drop back in punt\nand the treatment plan is going to show and the reassessment is going to show\nwhy you changed gears or changed directions so nobody goes well what in\nthe world happened there you know I thought she was gonna discharge and then\nthree months later she&#39;s still on the unit what&#39;s going on well you know we\ncan we were able to justify why that was important\nit substantiates the need for further assessment and testing if you have a\nclient who comes in who may have fetal alcohol spectrum issues you know because\nwe know that alcoholism runs in families it&#39;s not uncommon for clients to have a\nmother who was an alcoholic now you know I&#39;m not saying that every mother&#39;s an\nalcoholic and every person who has an addiction has a parent a mother who&#39;s an\nalcoholic but I&#39;m saying the likelihood is higher if you&#39;re working with\nsomebody with an addiction that their mother and for fetal alcohol spectrum\ndisorders this has to be the mother because it&#39;s taint damage to the fetus\nthat&#39;s done in utero so you know dad doesn&#39;t have anything to do with that so\nif you think the person has FASD or an F ASD you can refer because you need to\nget neurocognitive testing and all kinds of other things done but that will help\nthem get set up for higher level services and reimbursement on multiple\nlevels through SSI potentially if they have significant impairment its\ndocumentation supports termination or transfer of services if they&#39;ve reached\nmaximal gains at this level of care it&#39;s going to show or and kind of along the\nsame thing if something happens and they can&#39;t participate in this level of care\nright now they need to be transferred to a crisis stabilization unit\ndocumentation will show why they were discharged from one place and sent to\nanother it identifies problems with service delivery by providing data to\nsupport corrective actions when I worked at the facility I worked out we had\nmultiple programs we had case management and outpatient residential and detox and\ncrisis stabilization and yada yada yada and sometimes there would be too\ncooks in the kitchen so referrals wouldn&#39;t go off as planned or one person\nwould think they were running the master treatment plan while another program\nwould think they were running the master treatment plan and then reimbursement\nwould get messed up so we were better able to figure out who was the single\npoint of contact for this client and what the treatment plan was adding two\nmethods to improve and assure quality of care so if we figure out that yeah this\nis working really well but you know we have this great intensive outpatient\nprogram but our aftercare program is really non-existent and it&#39;s it&#39;s\nimperative to have an aftercare program let&#39;s look at how we can do this in\norder to help people stay clean and sober it provides information that&#39;s\nused in policy development program planning and research another example\nthat we used during the time that I was working at the at that clinic we\nrealized that there was a need for a mother baby unit there wasn&#39;t one in our\n13 County region so we wrote a grant and we created a unit that reached out to\nmothers who were still pregnant ideally didn&#39;t have to be but ideally\nstill pregnant we helped them stay clean and sober until they delivered and then\nthey stayed with us for another six months so we identified a gap in\nservices you know because pregnant and postpartum women were really not getting\na lot of services and we met that need and documentation provides data for use\nin planning professional development activities it helps you see what might\nbe a need if you&#39;ve suddenly got a lot of people coming in who have trauma\nissues then staff maybe need to be trained on trauma focused cognitive\nbehavioral or cognitive processing therapy in order to better serve that\nparticular population or you may have an influx of clients from a different\nculture you know right now in Florida there are a lot of people that have come\ninto Florida from Puerto Rico after the hurricane so there&#39;s a need for services\nthat are truly sensitive to people from Puerto\nRico so it helps you identify who&#39;s coming through our doors what are their\nneeds and what kind of training would benefit our staff so they can serve them\nmore effectively and it fosters communication and collaboration between\nmultidisciplinary team members a lot of times I would never see the doctor or\nthe psychiatrist when they would come to see the clients that were on residential\nbut I knew that they were reading my notes and they knew I was reading their\nnotes because we had to initial so it made sure that all of the people in the\nteam are at least communicating via the chart if not a team meeting unfortunately when you get into\ndocumentation you also get into big sticky issues with confidentiality and\nwith substance abuse you need to be really aware of the Code of Federal\nRegulations 42 part 2 or CFR 42 part 2 and this handles the confidentiality of\nalcohol and drug abuse page patient records 42 CFR part 2 applies to all\nrecords relating to the identity diagnosis prognosis or treatment of any\npatient in a substance abuse program in the u.s.<\/p><br><p><img src='https:\/\/images.pexels.com\/photos\/2865901\/pexels-photo-2865901.jpeg?auto=compress&#038;cs=tinysrgb&#038;h=650&#038;w=940'><\/p><p>So this is in addition to HIPAA\nand hi-tech and all of those substance abuse clients have additional\nprotections there&#39;s a prohibition data that would identify a patient as\nsuffering from a substance use disorder or as undergoing substance use disorder\ntreatment you can&#39;t identify that information unless you have a specific\nrelease of information so if you&#39;re seeing somebody for mental health issues\nbut they&#39;ve also got you know a substance use disorder\nyou can&#39;t divulge that that&#39;s separate information and their record is extra\nprotected 42 CFR part 2 allows for disclosure where the state mandates\nchild abuse and neglect recording sometimes the child abuse and neglect is\ndirectly related to the substance use or you&#39;re the only provider and you&#39;re in a\nsubstance abuse treatment program and you have to make a mandated report\nyeah it&#39;s allowed it allows for disclosure when cause of death is being\nreported so if you have a client in your program who dies and you have to report\nthe cause of death you can disclose at that point or if the\nclient passes away when they&#39;re on your on your facility and unfortunately it\nhappens sometimes then you know obviously people are going to know where\nthat person died because the everybody&#39;s going to come pick them up and do the\ninvestigation and you can disclose when there&#39;s an existence of a valid court\norder sometimes the courts will say this is\nimportant to know and that&#39;s varies by jurisdiction so in order to release\ninformation you have to have a written release and a written consent requires\n10 elements and this is so important because so often I see releases of\ninformation that don&#39;t contain all ten elements number one do not ever have a\nclient sign a blank release of information you know saying you know\njust in case we need it just sign it so I haven&#39;t know that&#39;s a big big big big\nno-no so anyway the release of information to be valid and if it&#39;s not\nvalid then technically you can&#39;t release the information so it has to have all\nten of these elements the names of the program&#39;s making the disclosure the name\nof the individual or organization that will receive the disclosure the name of\nthe patient who is the subject of the disclosure you know that&#39;s all pretty\nstandard the specific purpose or need for disclosure that gets a little bit\nyou know why are you making this disclosure because the client requested\nit because of a court order in order to coordinate care what&#39;s the need a\ndescription of how much and what kind of information will be disclosed generally\nit&#39;s not everything you need a special release of information according to\nHIPAA in order to release progress notes as opposed to release other information\nso you know on ours we have we&#39;ll check boxes so you can identify\nwhether its assessment attendance drug trip drug testing results etc you have\nto have a patient&#39;s right to revoke the consent in writing and the exceptions so\nthere has to be a paragraph somewhere that lets the patient know that they\nhave the right to revoke consent in writing you know at any time unless and\nthere are a few exceptions but there they&#39;re few and far between and your\nlegal department will handle that some agencies say clients can revoke consent\nverbally however the requirement is only that it\nhas to be done in writing so if a client wants to revoke consent they need to\nwrite it down and give it to you showing that they want the consent revoked and\nthen you know if they&#39;re there you cross through the the consent form you write\nvoid you date it you put your initials on it and they put their initials on it\nthat&#39;s the ideal situation they can mail in a letter revoking consent as well you\nhave to have the date or condition when the consent expires if not previously\nrevoked now my program we always did a standard one year or 90 days depending\non the program unless the client revoked consent however your program may be\ndifferent or the client may choose the wind&#39; the timeframe the signature of the\npatient and\/or other authorized persons so if the patient is a minor or is not\nable to sign for themselves and they have an authorized representative\nyou know you need those signatures your signature and the date on which the\nconsent is signed so generally you have a witness there and you have the date\nthat the witness and the person signed it so it has to have all ten of these\nthings when used in the criminal justice setting expiration of the consent may be\nconditioned upon the completion or termination from a program so when Jim\nBob gets released from jail this consent expires is can happen\ninformation can be shared within an agency on a need-to-know basis only with\npeople on the treatment team only so it need to know you know if you&#39;re not on\nthe treatment team then you don&#39;t need to know so we used to have this big\nmedical records room and you would walk into it and there were literally\nthousands of files could I have pulled a file off the off-the-rack and looked at\nit and read it yeah I could have but that&#39;s not okay that is a violation of\nHIPAA as well as a bunch of others because I have no need to know about any\nrandom patient that is being seen so it&#39;s important to make sure that you&#39;ve\ngot good control over who can access records information sharing can be done\nwith the release it can be done to the client you don&#39;t have to have a release\nto give the information to the client or under specific circumstances and that\ngoes into confidentiality we&#39;ll talk about a little bit later agencies\ngenerally have policies for who is allowed to release information so the\nlady at the front desk probably can&#39;t release information it probably has to\ncome from the therapist or from the risk manager clients have the right to review\nand amend their records if they request to view or amend the record is denied\nthen we must provide a written explanation to the client so you know\ngenerally write your notes and write your everything assuming the client is\ngoing to read it use objective information don&#39;t be you know derogatory\nin any sort of way explain your findings and you know keep the client involved if\nthey request to amend the record and and the agency denies it for some reason it\nsays no you can&#39;t see your record or no you can&#39;t amend it there has to be a\nreally really good reason we had some circumstances where the client wanted to\namend the record and our executives decided that the amendment they were\ngoing to make was not didn&#39;t seem to really have a good grounding in reality\nthe client was allowed to submit their amend\nin their handwriting and it was added to the case file and noted that this was a\nclient amendment to the case file so your agency may handle it multiple ways\nbut unless you provide them really good reason they have the right to review and\namend the record now that doesn&#39;t mean take out something that you put in there\nbecause once something&#39;s in the record it&#39;s in the record henceforth and\nforevermore but they can add an addendum and so can you all right HIPAA and\nhi-tech these protect insurance coverage of workers when they&#39;re when they change\nor lose their job this is the idea what it was supposed to be for its safeguards\nthe privacy of their information so if you&#39;re changing jobs or whatever you\nknow nobody can really access your information to find out anything about\nyou before they hire you etc it combats waste in healthcare delivery because it\ninsures or hope hopefully ensures that we&#39;re communicating and the portability\npart of HIPAA means clients can take their record from one place to the other\nso you don&#39;t have to duplicate the intake and all a bunch of the other\nstuff necessarily and it simplifies administration of health insurance\nthose were the that was the hope of HIPAA it kind of ballooned out of that\nso what do we need to know about HIPAA medical records are legal documents all\nstates have policies regarding record retention medical records of adults are\nretained for seven years medical records of minors may be retained for longer so\nyou need to know what your state requirements are agencies and solo\npractitioners should have policies identifying retention and storage\npolicies so how long do you store it how do you store it how do you keep it safe\nwho has access to it yada yada yada back to CFR 42 all\nrecords must remove patient identifying information and sanitize software\nprinter ribbons FAQs hard drives and printer hard drives when you&#39;re talking\nabout disposing of files you need to dispose\nof them in a way that removes patient identifying information and if you use\nhard copy still if you have software and this includes the hard drive in your\ncopier a lot of people forget that one that has to be wiped and printer ribbons\nhave to be destroyed fax hard drives have to be destroyed and\nprinter hard drives have to be wiped and I guess wiping is really what we&#39;re\ncalling it you don&#39;t have to actually physically destroy it but it has to be\ncompletely wiped don&#39;t just delete the file if you delete the file it goes in\nbits and pieces into your computer&#39;s never-never-land so to speak but people\ncan put those pieces back together that&#39;s actually what my husband does for\nhis you know career is find those pieces that have had been lost or somebody\ntried to delete something and he gets it back all client records and identifying\ninformation must be kept out of sight of unauthorized personnel well we know that\nso we keep our records behind to close to closed and locked doors okay that&#39;s\ngreat we have passwords in order to get into\ncomputer systems that&#39;s great but there are other things like lists and rosters\nyou know sign-in sheets technically are supposed to be kept out of sight and\npeople aren&#39;t supposed to be identifying information attendance records you don&#39;t\nwant have want to have clients coming up and signing their own attendance record\nwhere they can see who and their groups been there for the past five days and\nwho hasn&#39;t appointment schedules you don&#39;t want to be a client a client to be\nable to see what your schedule is for the week and who&#39;s coming in to see you\ncomputerized information must be on an encrypted hard drive full encryption of\nthe whole hard drive not just that one folder client records need to be kept\nyou know secure and phone messages you don&#39;t want to have the secretary\nsitting there with 17 phone messages across her desk while other people are\ncoming in and checking in and then looking and going oh I didn&#39;t know Bob\nJones was the client here so you need to make sure that phone messages are kept\nyou know if they have the little message sheets keep them in a like a cigar box\nor a pencil box and then disseminate them to the therapists as appropriate\ntherapists do the same thing don&#39;t have receipt books or phone messages just out\nwhere any client can see them if you discontinue your program you decide to\nclose your practice or your practice gets bought by somebody else it must you\nmust remove patient identifying information from your records or destroy\nyour records including sanitizing any associated hard copies or electronic\nmedia to render the patient identifying information non retrievable in a manner\nconsistent with the policies and procedures established under CFR 42 part\n2 unless the patient gives written consent to transfer the records to the\nacquiring program so if somebody buys your program your your practice you have\nto keep those files for that 7 year period or whatever but and you&#39;re not\ngoing to transfer those unless you have written release from the client or if\nthere&#39;s a legal requirement that records be kept for a period specified by law\nwhich doesn&#39;t expire until after the discontinuation or acquisition of the\nprogram so again if you haven&#39;t met your 7-year requirement that&#39;s generally a\nlegal requirement you still have to hold on to those records but you&#39;re not going\nto pass them on and definitely not pass them on with\npatient identifying information to the new program unless you have a written\nrelease records which are paper must be sealed in envelopes or other containers\nand labeled as follows records of insert name of program required to be\nmaintained under insert the statute or regulation until a date no later than\ninsert the appropriate date so basically it says I have to hold on\neverything in this box or in this envelope that is sealed until XYZ date\nand time at which time it will be destroyed all hardcopy media from which\nthe paper records were produced also need to be sanitized in order to render\nthe data non retrievable records which are electronic must be transferred to a\nportable electronic device with implemented encryption so a hard drive\nthat has that is encrypted so there&#39;s a low probability of assigning meaning\nwithout the use of confidential processes or key so you know what&#39;s on\nthat hard drive it&#39;s encrypted so nobody else can access it even if you know they\nwere to put it into a computer but you still have the client information there\nthe electronic records must be transferred along with a backup copy to\nseparate electronic media so that both records and the backup have implemented\nencryption so you don&#39;t want to just have one hard drive because hard drives\ncan fail you need to have backups in order to say you&#39;re securely sir\nsecurely saving the data within one year of the discontinuation or acquisition of\nthe program all electronic media on which the patient records or patient\nidentifying information resided prior to being transferred must be sanitized so\nagain you want to check with your legal department to see where the seven year\nrule falls but if it&#39;s outside of that seven year rule then definitely within a\nyear after that the information needs to be destroyed portable electronic vise\ndevice or the original backup electronic media must be sealed in a container\nalong with any equipment needed to read or access the information this is\nimportant because technology moves quickly and you know back when I started\nworking on computers we had those you know five and a quarter floppy disks you\ncan&#39;t find a computer now that can read those most computers don&#39;t even have CD\ndrives in them anymore everything has to be on a thumb drive so you need to make\nsure that not only is the information there\nbut it will be readable in the future and then there&#39;s a special thing records\nof this program required to be maintained under this legal authority\nuntil a date not later than duh so you want to label everything so you know\nwhat it is when it&#39;s to be destroyed okay so many agencies govern the content\nscope and quality of documentation the single state authority or SSA in your\nstate has state service and licensing rules so it&#39;s important to communicate\nwith your SSA and that&#39;s generally also the agency that does your licensing so\nwhen you get licensed as an independent provider you&#39;ll know what the\nregulations are the SSA may set forth time frames for documentation completion\nand who needs to sign and credential the documents so if you&#39;re a registered\nintern or you&#39;re not certified yet who has to co-sign on your documentation\naccreditation bodies also put their two cents in about documentation and they\naddressed quality from an organizational leadership and client care perspective\nso generally accreditation bodies are looking at quality of care and quality\nof documentation so good quality documentation will hopefully show good\nquality care many agencies govern the content scope and quality of\ndocumentation including third-party payers who set the guidelines through\ntheir level of care guidelines and other provider agencies so if you are when I\nworked with the Department of Corrections for example they had certain\nvery specific requirements for the documentation of my clients so what\ntypes of documentation are there there&#39;s lots screening is the first type of\ndocumentation and good screening identifies the referral source the\npresenting problems background biopsychosocial information and this\nisn&#39;t going to be an in-depth everything but it&#39;s going to get a general idea\nabout what&#39;s going on so we can rule out or rule in physical issues social\nrelationship interpersonal issues as well as psychological issues is going to\nnote the person&#39;s emotional and mental status at that time it will note their\nstrengths and preferences for treatment for recovery for interventions and it\nwill make a recommendation for assessment or other referral as needed\nso sometimes screenings just happen like it workplace affairs the screening\nhappens and it&#39;s like yep you seem to be fine\nno further action needed by the bank and that chart is closed for others you may\ndetermine that the person may need a physical to rule out you know things\nlike hyperthyroid that may be causing symptoms that look like hypomanic\nsymptoms or look like stimulant intoxication you may need to refer to\ndetox you may there are a lot of referrals that may need to be made but a\nscreening is not a diagnostic interview it&#39;s when you identify whether there&#39;s a\nlikelihood that the person may have a problem that needs further assessment\nintervention documentation so intervention is like your entry level\nservices intervention documentation includes client identifying information\nthe source of the referral client placement information you know why were\nthey put into your program when were they put in how long are they going to\nbe there the screening information that got them to that point informed consent\nfor services including any drug testing that may be required and drug testing\nhas its own form that needs to be signed dated credentialed by the client and\ncounselor and witnessed and if you&#39;ve done drug tests you know all this but\nit&#39;s important to get that informed consent for intervention services\nthere&#39;s a release of information that has all the ten necessary components as\nneeded so if you need to talk to a referral source get a release of\ninformation signed the intervention plan which is a lot broader or whatever you\nwant to say than a treatment plan is signed dated and credentialed by the\nclient and counselor and witness so you know\nyou know this with your documentation you&#39;ve probably done this already you\nknow with intakes and everything else the client signs it you sign it you both\ndate it and you have to make sure your credentials are on it if you&#39;re not\nalready certified or licensed then you have to have somebody who is certified\nor licensed cosign on it most of the time intervention documentation also\nincludes copies of correspondence or reports with referral sources and a\ntransfer or discharge summary at the end of the intervention service\nadministrative documentation in general this is going to be the stuff that&#39;s\nused for billing it&#39;s not the clinical it needs to be accurate concise include\nrecommendations referrals case consultations legal reports family\nsessions and discharge summaries what you&#39;re like well that&#39;s kind of clinical\nisn&#39;t it a little bit but in order to get reimbursed the administrative side\nof things we have to have good documentation in all of those areas\nadministrative documentation is conducted at admission and specified\nintervals throughout care so your administrative documentation is going to\nbe a reassessment it&#39;s going to be your treatment plan updates it&#39;s going to be\nall of those things so types of administrative documentation your client\nidentifying and demographic information referral source name and address\nfinancial information assigned client rights document assigned informed\nconsent for treatment document any releases of information that you need\nassigned orientation to the program indicating that the client did receive\norientation outcome measures that help identify whether your program is being\nsuccessful and when you know when JimBob meets these criteria he or she is going\nto be ready for discharge and client placement information that goes back to\nyour a sam or your locus medical documentation which is often in another\nsection of the file includes the medical history the nursing assessment the\nphysical exam the lab tests which almost always have to include\na TB and pre-admission physical records of medical prescriptions and changes in\nmedications that occurred you know what prescriptions were the person on when\nthey got there and what what did they take while they were in your program\neven if you&#39;re not residential you need to know what meds they&#39;re on and any\nchanges that their doc may make or your doc and what are they discharged with\nyour medication administration records so if you&#39;re in residential then the\nclient is probably going to or may receive medication while he or she is\nthere so the medication administration records need to become part of the chart\nto show you know when Jim Bob took his medication who administered it and\nyadda-yadda and nursing notes so any notes that your staff nurse makes\nregarding the client&#39;s progress now clinical documentation is the stuff that\nwe enjoy doing screening assessment treatment planning progress notes and\nyour discharge summary so we&#39;re going to get into those in the\nin a few minutes I do want to mention electronic health records really quickly\nbecause you know you have all this administrative medical and clinical\ndocumentation a lot of times now it&#39;s going into an electronic health record\nhealth information technology is the secure management of health information\non computerized systems it helps track data over time track progress of those\nwho leave treatment and monitor quality care within practice just like\ndocumentation does but when it&#39;s on a computer it&#39;s a whole lot easier to run\na program and get pretty little charts spit out behavioral health lags in\nadoption of these electronic health records because of cost technical\nlimitations you know there&#39;s a lot of different players who want different\nthings so creating a standardized electronic health record for behavioral\nhealth has been really difficult lack of standardization of data elements lack of\ninteroperability of systems between you know doctors and therapists and whatever\nyou know you have to have if your doctor has a system made by X Y Z and you have\na system made by Acme they still have to be able to talk it&#39;s kind of like\ngetting an apple or a Mac computer and a Windows computer to talk doesn&#39;t always\nhappen so we need to make sure that the different electronic health records out\nthere can communicate with one another attitudinal constraints we don&#39;t like\nchange an organizational lack of expertise in health information\ntechnology management most programs don&#39;t have a technology director\nespecially smaller programs so integrating this is really overwhelming\nand it can be really costly if everybody has to have a computer in order to put\nin there their client information general elements of clinical\ndocumentation whether it&#39;s administrative clinical or medical must\nbe clear concise accurate written in ink time stamped or dated so you have to\nhave all that information in there if you write\nI&#39;ve had some staff members their handwriting was atrocious you could not\nread their notes or their assessments to save their life that is not good\nclinical documentation because it doesn&#39;t help anybody documentation is an\nongoing responsibility for all professionals and should be completed as\nsoon as possible after the contact don&#39;t wait until Friday to do all your notes\nfor the week ethically you need to do it as soon as possible and I&#39;ll give you a\nlittle hint when I do groups oftentimes I will have a sheet that I pass out at\nthe end of group has the client identify three things they got out of group and\nthen you know a couple other questions about you know how they&#39;re feeling if\nthey feel like they need a treatment plan reassessment and just a few other\nthings to give me information then I have something in the clients\nhandwriting to put in the chart but I also have the brunt of the progress note\nkind of done already and if you use soap notes or DAP notes you can kind of put\nthat on there and have the client fill out what they think they would put for\ntheir notes that&#39;s helpful in group for individual individual sessions are\ngenerally supposed to be 45 to 50 minutes so I end right about 45 minutes\nmaybe a little longer tend to run late and the client and I create the progress\nnote together that way they review what we talked about they review the progress\nthey&#39;ve made they review what they&#39;re supposed to be doing in the upcoming\nweek and they know what&#39;s going in the chart so it&#39;s not mystical and magical\nyou know they are an active participant and I have the note done before the end\nof the hour so it&#39;s kind of a win-win-win all around\nokay documentation of sure&#39;s accountability the responsibility for\naccurately representing the client situation rests with the counselor and\nthe clinical record not the client so like I&#39;m saying we can get all of this\ninput from the client but making sure that it&#39;s accurate when we put it in\nthere and you know pulling it all together is incumbent upon us\ngood clinical documentation spares the client from repeating painful details so\nwe&#39;re not going to have them you know if you&#39;re talking with a client about a\ntrauma situation you&#39;re gonna put enough in your clinical record that you don&#39;t\nhave to have them remind you you know remind me again about what happened when\nyour house burned down or what no that&#39;s rude um so you want to have enough\ndocumentation that gives you an overview or the next counselor sort of an\noverview of what happened and then if they need to delve into details later\nthey can language language must be objective but descriptive so if you&#39;re\nsaying that the client is decompensating well that doesn&#39;t tell me anything\nin what way as evidenced by you know the client is I diagnosed with the client\nwith depression because they have these symptoms as evidenced by that is your\nbest friend phrase as evidenced by documentation must identify persons\nplaces direct quotations and sources of information so if the client says you\nknow I&#39;m really feeling off my game you can put that in there so we know kind of\nwhere the clients coming from we want to use direct quotes from collateral\nsources that we get and identify who gave us this information clinical\ndocumentation is a legal record and the clinicians signature and credentialing\nindicates the truthfulness of it so if you sign it then it happened the\ntreatment plan good treatment plans are hard to come by they&#39;re really easy to\nwrite if you don&#39;t overthink it but I find that most people overthink it so\nthere&#39;s a hole that&#39;s actually a couple of classes on treatment planning because\nit is so important not only to guide treatment but to help clients learn how\nto set goals and achieve them treatment plans are a contract between the client\ncounselor and treatment team each being responsible for its development and\nimplementation the clinician needs to recognize that treatment occurs in\ndifferent settings over time so you know treatment may be happening but you know\ncounseling is only part of what going on there also in maybe case\nmanagement or vocational rehabilitation or you know so treatment occurs medical\nin different settings and we need to be able to integrate all that into the\ntreatment plan much of the recovery process occurs outside of or immediately\nfollowing formal treatment when people do their homework assignments and they\nhave their aha moments when they generalize their progress when they\ncreate that support system on the outside treatment is often divided into\nphases engagement stabilization primary treatment and\ncontinuing care treatment planning plots out a roadmap for the treatment process\ntreatment plans are completed once a diagnosis is made a level of care is\ndetermined and the client is admitted to the program now after the initial\nassessment there&#39;s usually an initial treatment plan done but the real\ntreatment plan generally needs to be completed within three to five days\nafter admission once the clinician has finished the assessment paperwork and\neverything level of care is determined based on diagnosis and the clients\nstrengths and assets so if you&#39;re familiar with the a Sam for example\nrecovery environment is one of those dimensions that we look at and if\nthey&#39;ve got a really strong recovery environment then the option may be or\ndecision may be made to refer the person to eiope instead of residential whereas\nif they have a really poor recovery environment then we may opt to refer the\nperson to residential so they have a better chance in the first 30 to 60 days\nof you know getting a handle on things treatment plans address all\nbiopsychosocial needs not just mental health they establish what changes are\nexpected through achievable goals clarifies what interventions and\ncounseling methods will be used to help the patient achieve those goals sets the\nmeasures that will be used to gauge success and that&#39;s where we go with as\nevidenced by again so if the client says you know instead of saying I&#39;m going to\nquit using drugs they may say I&#39;m going to develop a healthier life\nso how do we know when the client has developed what he or she defines as a\nhealthier lifestyle well as evidenced by I&#39;m going to develop a healthier\nlifestyle as evidenced by getting eight to nine hours of sleep a night eating a\nrelatively nutritious diet as decided upon but between myself and the\ndietitian developing healthy support systems yada yada\nyou see what I&#39;m getting at so you&#39;re going to be able to go through and\nanybody would be able to go through and Mark off and say either yes or no\nachieved it achieved it achieved it achieve the goal so it&#39;s kind of a yes\nor no thing treatment planning incorporates the clients strengths needs\nabilities and preferences and I&#39;m big on this you all probably know that if you\ntook our addiction counselor certification training course\ntemperament is huge extroverts and introverts have different needs judgers\nand perceivers have different needs auditory and visual learners have\ndifferent needs and people in general based on their culture and just their\ncognitive aptitudes are going to have different strengths and needs so we want\nto form the treatment plan around the clients strengths and build off what&#39;s\nalready there what already works referrals are made to other agencies as\nneeded when referrals are made collaboration is essential to keep\nclients from falling through the cracks so treatment planning is going to\nidentify you know client will get enrolled for Medicaid well you&#39;re\nprobably not going to do that so you&#39;re going to identify who the client is\ngoing to see at whatever office they&#39;ve got to go to in order to get enrolled in\nMedicaid but that&#39;s going to be part of the treatment plan treatment planning\ninformation even within the agency is restricted to need-to-know and treatment\nplans may have to be co-signed by a clinician who is already certified or\nlicensed the function of the treatment plan well treatment planning is an\naction-oriented process that lays out logical goal directed strategies for\nmaking positive changes just like if you&#39;re going to make\nlasagna from scratch and you&#39;re gonna follow a recipe same sort of thing here\nand based on your preferences you know when I make my marinara sauce I use roma\ntomatoes that is my preference I know other people who use different kinds of\ntomatoes so different preferences I know that I want to do it in a shorter period\nof time so I&#39;m not going to make the the noodles from scratch that&#39;s a need that\nI have because I don&#39;t have the time to make noodles from scratch so my recipe\nis going to be slightly different than my stepfather&#39;s recipe but that&#39;s okay\nand treatment planning is the same way just think of it very very\nsimplistically like a recipe don&#39;t get too overwhelmed and tried trying to make\nit too complex because clients aren&#39;t going to be able to make complex\ntreatment plans and treatment planning establishes a collaboration between you\nand the client so you can mutually prioritize agreeable goals you figure\nout what do you want I&#39;ve worked with clients who were involuntary and you\nknow they didn&#39;t really want to quit using however they were on probation and\nthey wanted to get off probation well I wanted them to get off probation but I\nwanted him to quit using in order to get off probation they had to be clean\nduring the time they were in treatment so that became our goal because that was\nmutually agreeable you know it&#39;s like well your goal is to get off probation\nin order to do that you got to stay clean so let&#39;s work together to make\nthat happen during the next 16 weeks and generally it worked that way achievable\ngoals are selected by assessing and prioritizing client needs and taking\ninto account their level of impairment if you&#39;ve got a client who is\nsignificantly impaired they&#39;ve got major clinical depression they&#39;re detoxing\nfrom five years of stimulant abuse they&#39;re not going to be going out and\ngetting a job next week that&#39;s you know well down the road so the goals we&#39;re\nlooking at now are more like stabilization and engagement you want to\ntake into account motivation what does the client want to achieve because\nthey&#39;re not going to be real motivated to achieve what you want\nto achieve unless they want to get out they want to get discharged from the\nprogram successfully and in order to do that they&#39;ve got to meet your goals but\nideally help them identify goals that are meaningful to them and you&#39;re going\nto look at the real world influences on needs so if they&#39;re going to be\ndischarged in 30 days even though they may not be quite ready to start looking\nfor housing if they need to have housing when they get out in 30 days then that&#39;s\nprobably going to be a high priority treatment plan goal because you don&#39;t\nwant them being discharged to the street treatment plants consider client needs\nreadiness preferences and prior treatment history looking at what did\nand didn&#39;t work because there&#39;s no sense repeating something that you&#39;ve done\nfour times that hasn&#39;t worked yet we&#39;re going to look at their personal goals\nand then we&#39;ll look at obstacles like transportation and childcare and those\nsorts of things that might preclude someone from going into residential or\nmake it difficult for them to get the evening IOP for example treatment plans\nhave SMART goals specific measurable achievable realistic and time limited\nthese goals are broken down into smaller objectives so you know think about it\nlike you want to climb a staircase well that&#39;s great that&#39;s your goal you want\nto climb a staircase in the next 45 days wonderful you&#39;re gonna be taking a\nlittle while at each step but each step is an objective so your end goal is the\ntop of the staircase what is the first thing you need to do to start moving\ntowards the top of that staircase what&#39;s your first step all right once you get\nthat done what&#39;s the next thing you got to do again think of the recipe first\nthing you&#39;ve got to do is find the recipe then you&#39;ve got to figure out\nwhat you&#39;ve got on hand then you&#39;ve got to figure out you know what you need\nfrom the store then you&#39;ve got to go shopping you know one step at a time\ndon&#39;t make it too complex treatment plans anticipate the type duration and\nfrequency of services so you know a lot of times we may say if they&#39;re in IOP\nthere&#39;s going to be three hours a day five days\nweek for the first month and then once they accomplish certain goals then they\ncan step down to three hours a day three days a week\netc treatment plans identify who&#39;s responsible for what so if the client\nhas to go do something it&#39;s going to be clearly indicated that the client needs\nto make the appointment with social services to get enrolled in programming\nversus the counselor will make the appointment for the client to go to\nSocial Services you know whoever supposed to do it it needs to be noted\nand there has to be a timetable you know this needs to be accomplished by X date\nif it doesn&#39;t get accomplished by X date it&#39;s not the end of the world however\nyou need to do a reassessment and go okay why didn&#39;t this happen\nwhat do we need to adjust it incorporates client input and\nparticipation in development it helps the client prioritize presenting issues\nso I mean they come in and generally there&#39;s a whole litany of stuff that\nthey need to work on and it can feel really overwhelming\nbut I liken it to a woven blanket for clients that woven blanket is over your\nhead right now you can&#39;t breathe you can&#39;t see it&#39;s miserable it&#39;s hot any\nstring you pull on is gonna start making air holes in that blanket and making it\nlighter and eventually you will unravel the whole blanket so let&#39;s figure out\nyou know of the issues that you&#39;ve got going on right now which are most you\nthink are most important to work on and which are you most motivated to work on\nwhat string are you willing to pull first you get input from client on their\ngoals and objectives so what is there as evidenced by look like you know if I am\nhappier as opposed to being depressed what is that going to look like if I am\nhealthier as opposed to unhealthy what is that going to look like how am I\ngoing to know when I&#39;m living a healthier lifestyle and both the\ncounselor and client sign the plan the clinician may also facilitate and manage\nreferrals because oftentimes we don&#39;t have case management that we can rely on\nat minimum the plan is a flexible document that uses a stage match process\nto address identified substance use disorders\nso stage match process if you think back to the stages of readiness for change\npre contemplation contemplation preparation action and maintenance each\nstage requires different interventions so that&#39;s tip 35 from Samsa if you need\nto refresh it looks at the recovery support environment\nit addresses potential potential mental health conditions you know based on\nreadiness for change for that issue you know somebody may be in the action stage\nof readiness for change on their substance use but not you know ready to\ndo a lot about their anxiety it&#39;s usually the opposite but whatever so you\nneed to make sure that you stage match by issue because the person is not just\ngoing to be globally in the action stage of change there are going to be some\nthings that they&#39;re not really that ready to work on yet you want to\nidentify potential medical issues employment education spiritual issues\nsocial needs and legal needs and there are other things like childcare and\nother wraparound services that can go into this too but these are the big ones\ninitial treatment plans are done an admission or within 24 hours based on\ninformation from the assessment and screening and serves as the initial\nroadmap they include presenting problems preliminary goals type frequency and\nduration of service and the signature and date of the client and counselor\nwith counselor credentials so again this is the initial treatment plan as you get\ninto treatment and start to know the client a little bit better you&#39;re going\nto formulate a more in-depth treatment plan this one has to be done either at\nadmission or within 24 hours an individualized treatment plan has the\nproblem and a problem description that answers the question why are you here\nthat&#39;s the problem not the goal I&#39;m here because I have a substance use disorder\nwhat&#39;s my goal to not have a substance use disorder it identifies the clients\nstrengths you know we are going to build on strengths so client will build on his\nto stay clean and sober yada yada it has concrete measurable goals concrete means\nyou can observe them you can see them you can either say yes it was done or no\nit wasn&#39;t not yeah it was probably accomplished it&#39;s yes or not the\nobjectives are there so that big goal is broken down into those smaller steps\nit has strategies for achieving those smaller steps so you know if the first\nstep is to start building a recovery support network well that&#39;s wonderful\nhow are you going to do that strategies answer how you start going to a a\nmeetings you know start going back to church call up your five closest friends\nthat are healthy supports whatever the treatment plan includes the diagnosis\nusually that&#39;s up at the top the signature of the client and counselor\nand the signature of the clinical supervisor if required ongoing\nassessment and collaboration is used to regularly regularly review the treatment\nplan and make necessary modifications many IOP and residential programs have\nto review the treatment plan once a week with the client and get the client to\nsign off sometimes you get a 30-day reprieve but you need to know what your\npayers and your state requires review should be completed at minimum at major\nor key points in the client&#39;s treatment course including admission obviously\nyou&#39;re going to develop it readmission you know maybe they discharged and they\nwere out for three months and then they relapsed and they&#39;re back well you may\nbe able to look at their treatment plan and see where they&#39;re supposed to be\nbecause they were in an IO P program and work with that but you&#39;re gonna need to\nreassess it at readmission at transfer at discharge if there&#39;s a major change\nin their condition such as you know they&#39;d have a manic episode or they&#39;re\nadmitted to the crisis stabilization unit for suicidal ideation you&#39;re gonna\ndo a reassessment and after 12 months regardless of what&#39;s going on after 12\nmonths progress notes document the clients progress in relationship\ntreatment plan goals and objectives each progress note should have the problem\nname and number because most clients will have like three treatment plan\nproblems and then multiple like say eight objectives underneath it so maybe\nsubstance abuse recovery is the first treatment plan problem okay so that&#39;s\nproblem number one and goal number a if you will the first goal is to start\ndeveloping a recovery support system so in the treatment plan if I talk with the\nclient about developing that recovery support system then I&#39;m going to\nidentify that we talked about problem 1a and what we what we addressed the\nprogress note identifies what the client says and does generally I mean you&#39;re\nnot going to do it verbatim it puts in counselor observations and assessments\nif the client seems to be doing really well as evidenced by and the clients\nobservations and assessments I always put those in there too how do they think\nthey&#39;re doing and what&#39;s their evidence as evidenced by and continued plans to\naddress the presenting problem you also may need to document any new information\nif they get into a new relationship get a new job breakup\nwhatever that will go in the progress notes the format for most people is the\nsoap format the first part is the specific objective information and the\nlast part is the assessment the interpretations and the plan for how to\nproceed you want to document the clients progress progress notes are based on\nwhat the client says and it does what the clinician observes the clients\nattitude demeanor nonverbals you know how compliant they are with treatment\nthe counselors knowledge and experience so counselors are going to be able to\ndifferentiate between a lapse and a relapse for example they&#39;re going to be\nable to differentially diagnose if the client starts presenting with some\nsymptoms of depression for example the clinician is going to rule out\nthe use of depressant substances they&#39;re going to rule out detoxification from\nstimulants they&#39;re going to rule out hopefully medical conditions and they\nmay rule in mood disorders or something so differential diagnosis is important\nto look at the physical and other potential causes for symptoms and danger\nto self or others I encourage my staff at every single treatment meeting to\nidentify whether the client had any suicidal or homicidal ideation espoused\nI mean if they said I&#39;m suicidal or I wish I could end it all that needs to be\ndocumented and to identify if the client had future plans was oriented to place\nand time you know just a general Mini Mental Status exam at every contact is\nreally good to protect you and even in group I mean you&#39;re looking at people\nand are they bright and are they oriented and are they talking about\nfuture things or they withdrawn and sad and tearful and talk about how you know\nthere doesn&#39;t seem any point in being there well you know if you hear that you\nprobably need to pull them aside and talk to them more in depth so you know\nget a some documentation that you had good contact with the client and you\nhave a good kind of idea about the pulse of things progress notes are not a\nverbatim transcript but a cohesive summary so one page you know don&#39;t write\na dissertation the discharge summary discharge planning begins at admission\ndischarge planning begins at admission okay I know I said it twice because it&#39;s\nthat important you see client Jim Bob and you know your things are going well\nbut then client Jim Bob goes out and relapses and never comes back\nwell he&#39;s discharged at that point you don&#39;t know when the client is going to\ndischarge necessarily so if you begin discharge planning at admission which\nactually is required by most insurance companies then you have a plan and you\nand Jim Bob have made a plan for this is how you&#39;re going to progress\nthese are the options and resources available to you so Jim Bob has\nsomething to work off of in case he never returns you want to\nsummarize in your discharge summary the service is delivered you know the\ndischarge summary is done when Jim Bob is actually discharging discharge\nplanning begins at admission so the discharge summary summarizes any\nservices you did deliver how well the client accomplished goals and objectives\nand any discharge recommendations including referrals continuing care etc\nthe elements of the discharge plan include the referral source you know\nbecause this is going to go back to the referral source saying Jim Bob\ndischarged this is the summary of what happened presenting problems and the\nreason for services treatment goals methods and outcomes outcomes generally\npertain to the person&#39;s ability to attain recovery build resistance and\nwork learn live and fully participate in the community of choice so discharge\nsummary is basically a big summary of the entire treatment episode it&#39;s going\nto indicate the condition of the client at discharge your prognosis and you know\nthat&#39;s a little subjective but we got to make it follow up recommendations\nincluding continuing care and the aftercare plan and the counselors\nsignature date and credentials you want to include the reasons for discharge on\nthe discharge summary but reasons for discharge can be varied treatment\ncompletion that&#39;s the idea they may lead leave AMA or against medical advice\nthat&#39;s not so ideal but it happens treatment non-compliance they&#39;re just\nnot getting with the program or they&#39;re showing up and they&#39;re under the\ninfluence or you know a variety of reasons that it&#39;s therapeutically\nindicated to discharge them or treatment was just incomplete you know again they\nleft before treatment finished they just it wasn&#39;t some what treatment incomplete\nis a lot like AMA but those are the four main reasons for discharge identified\nfor the review exam organization of documentation is gonna\nvary a little bit between each agency but each page has to have the clients\nname and some sort of identifying number all entries must be signed if you make\nan error in documentation you line through it once you don&#39;t scratch it out\nyou line through it once initial it date it and write error above it notes of any\nsort should never be removed from a file if you have late entries or Corrections\nthey&#39;re put in as a separate document and noted as an addendum to you know\nprogress note from to one of 18 or whatever so clinical document character\nat documentation characteristics need to be written knowing that others will read\nit it needs to be objective you know stay away from vague terms like client\nis doing well if you use a vague term then explain it as evidenced by uses\ndescriptive behavioral terms client is oriented to person place and time not\nclient seems to be with it today you know you want to use descriptive\nbehavioral kind of clinical terms it avoids jargon so you don&#39;t want to\noveruse clinical clinical terms and it keep it simple again remember the client\nmay read this it&#39;s concise and it&#39;s positive you know these are the steps\nthe client is making this is the progress the client is making yes the\nclient has had a setback but hey he returned for treatment and you know\nwe&#39;re picking up and figuring out what we did wrong you don&#39;t want to be\ndoomsaying and talking about how the client is non-compliant and resistant\nand just doesn&#39;t seem to want to be here and you want to keep it as positive as\npossible focusing on the strengths and the progress and making lemonade\nwhenever you your client gives you lemons all right well that was a lot\nthat we covered and I know documentation is not the most interesting thing but\nthat kind of hits the highlights of what you need to know for\nyour addiction counselor certification exam if you need more training we have\nlots of training at all CEUs calm and we have a full addiction counselor\ncertification track that is a little over 400 hours and of multimedia\ninformation and that&#39;s for one hundred and forty nine dollars alright thanks\nfor participating today or listening today and I will talk to you again soon<\/p><br><br><a href=\"https:\/\/www.youtube.com\/watch?v=ZyqF-w-myg4\" target=\"_blank\" rel=\"noopener\">As found on YouTube<\/a><p><a href='https:\/\/1867cbor3wkl8uafynqrqc3uzx.hop.clickbank.net'>Human Synthesys Studio It\u2019s Never Been Easier To Create Human Spokesperson Videos. No Learning Curve, So Easy To Use<\/a><\/p>","protected":false},"excerpt":{"rendered":"<p>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&#39;re supposed to do in documentation. Over the course of the next &hellip; <a href=\"https:\/\/effectsofanxiety.net\/archives\/150217\" class=\"more-link\">Continue reading <span class=\"screen-reader-text\">Documentation Review Addiction Counselor Exam<\/span><\/a><\/p>\n","protected":false},"author":3,"featured_media":150213,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":false,"jetpack_social_options":{"image_generator_settings":{"template":"highway","enabled":false},"version":2}},"categories":[1],"tags":[38507,34232,37888,38512,37897,37895,38513,38514,38515,37905,38531,38510,38518,38505,59869,36289,37878,38508,38509,59871,59809,59845,38533,38520,37893,37894,38517,38521,36776,38522,38523,38524,37876,38525,38526,59865,38532,38527,37906,38530,38506,35665],"class_list":["post-150217","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-anxiety","tag-adacb","tag-addiction","tag-addiction-counselor","tag-alcohol-and-drug","tag-cadc","tag-cap","tag-ccapp","tag-ccdc","tag-ce","tag-ce4less","tag-cebynet","tag-certification","tag-certification-board","tag-cheap-ce","tag-clinical-documentation","tag-coaching","tag-counseling","tag-counselling","tag-counsellor","tag-documentation","tag-donnelly-snipes","tag-exam-review","tag-homestudy","tag-ladac","tag-ladc","tag-lcdc","tag-lcsw","tag-licensed-counselor","tag-lmft","tag-lmhc","tag-lpc","tag-lpc-ce","tag-lpc-ceus","tag-naadac","tag-nbcc","tag-ncmhce","tag-online-ceu","tag-online-training","tag-quantum-units","tag-sex-addiction","tag-unlimited-ce","tag-ytccon"],"jetpack_publicize_connections":[],"jetpack_sharing_enabled":true,"jetpack_featured_media_url":"https:\/\/effectsofanxiety.net\/wp-content\/uploads\/2023\/01\/htmlF_IMG_63c590df3d883.jpg","_links":{"self":[{"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/posts\/150217"}],"collection":[{"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/comments?post=150217"}],"version-history":[{"count":0,"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/posts\/150217\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/media\/150213"}],"wp:attachment":[{"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/media?parent=150217"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/categories?post=150217"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/effectsofanxiety.net\/wp-json\/wp\/v2\/tags?post=150217"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}