Documentation: Assessment, Treatment Plans & Progress Notes

1. Documentation: Assessment, Treatment Plans & Progress Notes Jill S. Perry, MS, NCC, LPC, CAADC, SAP April 5, 2019 JP Counseling & associates, LLC 701 Sharon Road, Suite 2 Beaver, pa 15009 724-494-6750 www.jpcounselingcenter.org

2. What does COD Look Like? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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4. 5 Rules to Eliminate Stigma • Who remembers????? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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

6. Rules to Eliminate Stigma • DO: • Be a role model

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

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11. Actual Medical Quotes • The patient had waffles for breakfast and anorexia for lunch. • The baby was delivered, the cord clamped and cut and handed to the pediatrician, who breathed and cried immediately. • The patient was in his usual state of good health until his airplane ran out of gas and crashed. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

12. Actual Medical Quotes • I saw your patient today, who is still under our car for physical therapy. • The patient lives at home with his mother, father, and pet turtle who is enrolled in day care three times a week. • Examination of the genitalia was completely negative except for the right foot. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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

14. Actual Medical Quotes • Coming from Detroit, this man has no children. • Patient was alert and unresponsive. • When she fainted, her eyes rolled around the room. • Rectal exam revealed a normal size thyroid.

15. Keep Taking the Medicine Patient: It's been one month since my last visit and I still feel miserable. Doctor: Did you follow the instructions on the medicine I gave you? Patient: I sure did - the bottle said 'keep tightly closed.' JP Counseling & Associates, LLCHealing for Adults, Youth and Families

16. SAMHSA Addiction Counseling Competencies • The recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client-related data. • Demonstrate knowledge of accepted principles of client record management. • Protect client rights to privacy and confidentiality in the preparation and handling of records, especially in relation to the communication of client information with third parties. • Prepare accurate and concise screening, intake, and assessment reports. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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

18. Purposes of Clinical Documentation

19. To document professional work • To record what was done, by whom, with, to, for, and/or on behalf of whom, when, where, why, and with what results • To document assessment and differential diagnosis, treatment and other services provided, the patient's clinical course and clinical decision making (including assessment-based treatment and service planning and periodic reviews and modifications of the treatment/service plan) JP Counseling & Associates, LLCHealing for Adults, Youth and Families

20. Organization of Care • To record clinically meaningful information that the practitioner can later rely on to refresh his or her memory of crucial events in treatment, the patient's response to treatment and other services, problems experienced in treatment, key historical facts and details of substantive collateral contacts JP Counseling & Associates, LLCHealing for Adults, Youth and Families

21. Organization of Care • To create a longitudinal record of the history of the patient’s complaints, symptoms, comorbidities, assessments, diagnoses, treatment and other services provided, clinical course, and response to treatment and other services so that the treating practitioner and other practitioners who are, or who later become involved in working with the patient can use this information to identify potential trends, guide their assessment and guide their development and implementation of their treatment/service plans

22. Organization of Care • To provide a basis for practitioner reflection and self-supervision on the patient's evaluation, diagnoses, treatment and services, assessment-based treatment/service plan, clinical course and progress JP Counseling & Associates, LLCHealing for Adults, Youth and Families

23. Continuity of Care

24. clinically meaningful data • Assessment, diagnoses, treatment and other services provided, clinical course, progress and response to treatment and other services • Assessment-based treatment and service plans and the periodic reviews and modifications of those plans • Trends, crises and problems in treatment, so that they may have sufficient data based upon which they can provide meaningfully clinically informed continuity of care to the patient JP Counseling & Associates, LLCHealing for Adults, Youth and Families

25. Risk Management

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

27. Risk Management • ***if you didn’t document something of importance in the patient’s clinical record and that becomes the subject of contention in a legal or disciplinary proceeding against you, it can be treated by a court or administrative body as if it did not happen or you missed it or you ignored it or you did not address it, etc.

28. Risk Management • To document informed consent (i.e., for treatment, disclosure of information) and the nature and extent of the professional relationship and of duty owed with regard to the patient • To explain, detail and justify professional decision-making, problems encountered in working with the patient, and the professional response to crises and other special or problem situations • To record the details of supervision/consultation obtained in relation to the assessment and treatment of the patient, particularly with regard to crises or other special or problematic situations that arise JP Counseling & Associates, LLCHealing for Adults, Youth and Families

29. Risk Management • To record information that will support the adequacy of the clinical assessment, the appropriateness of the treatment/service plan and the application of professional skills and knowledge in the provision of professional services • To substantiate the treatment/services provided and the results of such treatment/services

30. Risk Management • For supervisors (who are legally professionally responsible and accountable for the professional services provided by their supervisees) to document each of their supervisory sessions, each of their contacts with the patients whose care they are supervising, and their oversight of the assessments, treatment and other services rendered by their supervisees under their supervision in order to enable them to defend the quality and appropriateness of their supervision and the quality of their supervisee’s professional work against any malpractice lawsuit or professional discipline complaint alleging negligent supervision or malpractice by them or their supervisee JP Counseling & Associates, LLCHealing for Adults, Youth and Families

31. Compliance

32. Compliance • To ensure compliance with clinical documentation and recordkeeping requirements imposed by federal and state (including licensing boards) laws, regulations and rules • To ensure compliance with clinical documentation and recordkeeping standards set by specific accreditation programs (i.e., TJC) and by health care institutions, facilities and agencies • To fulfill clinical documentation and recordkeeping requirements of various third-party payers (i.e. Medicare, Workmen's Compensation, Medicaid, insurance, managed care plans) JP Counseling & Associates, LLCHealing for Adults, Youth and Families

33. Quality Assurance & Utilization Review

34. Quality Assurance/Utilization Review • To record professional activities, the process and substance of assessment, differential diagnosis, treatment and service planning, clinical decision-making and the results of treatments and other services provided • To document the appropriateness, clinical necessity and effectiveness of treatments and other services provided • To substantiate the need for further assessment, testing, treatment and/or other services, or to support changes in or termination of treatment and/or services JP Counseling & Associates, LLCHealing for Adults, Youth and Families

35. Quality Assurance/Utilization Review • To facilitate supervision, consultation and staff/professional development • To help improve the quality of services by identifying problems with service delivery by providing data based upon which effective preventative or corrective actions can be undertaken to improve and assure the quality of care JP Counseling & Associates, LLCHealing for Adults, Youth and Families

36. Quality Assurance/Utilization Review • To provide data for use in planning educational and professional development activities, policy development, program planning and research in agency settings • To provide data to guide choices of continuing professional education programs to attend, ongoing review and revision of the organization and operation of the practitioner’s professional practice and research in private practice settings

37. Quality Assurance/Utilization Review • Having to prepare proper clinical documentation serves an important role of helping ensure quality patient care by making practitioners think about their patients, review and reflect on their therapeutic interventions, consider the efficacy of their clinical work and weigh alternative approaches to the care of their patients. • The capacity for professional self-reflection and self-appraisal of one's professional work is essential to a practitioner’s professional development, to the maintenance of his or her professional skills and to the provision of high quality clinical services. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

38. Quality Assurance/Utilization Review • Rather than viewing clinical documentation as a meaningless chore that consumes precious time, practitioners should view it in this light, as a form of self-supervision that is an essential element of their professional practice and of their provision of quality clinical services.

39. Coordination

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

41. Coordination • To ensure appropriate utilization of team members from multiple disciplines in order to bring to work collaboratively in an interdisciplinary/transdisciplinary manner the particular competencies of team members from various disciplines and/or who have specific specialties to maximize the quality of services to patients.

42. ELEMENTS OF GOOD CLINICAL DOCUMENTATION

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

44. Recording & Organization • Each entry in a patient record should be dated the day it is written. • If an entry in a patient record documents an interview, therapy session, missed session, any follow-up of the missed session, assessment or other substantive patient related collateral contact (i.e.; with another treating practitioner, with a family member, with the parents of a child who is in treatment) that took place earlier than the day the entry is written, the entry should include clear documentation of the day the activity being documented occurred. - JP Counseling & Associates, LLCHealing for Adults, Youth and Families

45. Recording & Organization • Any materials or information received regarding a patient which are entered in the clinical record should be dated and initialed on the day the information or material is initially reviewed and placed in the patient record. Additionally, some documentation should be written regarding the review of the material or information and any action taken as a result of that review. • All substantive collateral contacts with others relating to the patient and all referrals made relating to the patient should be documented contemporaneously in the patient’s clinical record. Timely follow-up on any referral made should be documented in the patient’s clinical record.

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

47. Recording & Organization c) progress notes, initial and interval updates of treatment/service plans and closing/termination summary d) referrals made, tests requested, and the reports of consultations, referrals or test results which are received e) communications with other practitioners received or sent relating to the patient

48. Recording & Organization f) non-professional correspondence to or from the patient or from non-professional collateral contacts g) billing records including copies of bills provided to patients, claims submitted to third-party payors, correspondence with patients and third-party payors relating to billing and payments (sometimes these are in a separate file) JP Counseling & Associates, LLCHealing for Adults, Youth and Families

49. Recording & Organization h. A chronological financial ledger by date: • (1) of services rendered - with the following information for each service [including separate services rendered on the same day]: date of service(s), description of service(s) with CPT [Current Procedural Terminology] codes, if the charge for a service is based on time spent the amount of time spent, and the charge(s) for the service(s) • (2) of financial transactions with the following information, the date and amount of the financial transaction, the nature of the transaction [payment, payment of coinsurance, denial of payment in whole or in part by third-party payor, etc.], the source of the transaction [patient, parent or guardian of patient, insurance or managed care third-party payor, etc.), write-off of charges and reason • (3) Running outstanding balance JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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