CLINICAL DOCUMENTATION TRAINING

1. Press ENTER for next slide. 1 CLINICAL DOCUMENTATION TRAINING Created by the Training Work Group - 2005

2. Press ENTER for next slide. 2 Training Information This training is one of four sections available sections. Following each section there will be questions relating to the material covered in that section. To obtain CEU�s, either complete the accompanying test; or, write down your name, social security number, contact information (address, agency, etc) on a piece of paper, along with the question number and answer to the question. Send your completed test or answers to: Region 2 Behavioral Health Providers, Inc, Attn: Quality Management Director, 2500 Camino Entrada, Suite B, Santa Fe, NM 87507. You can also fax your completed test or answers to: Region 2 Quality Management Director, 505-473-0374. If you have any questions relating to this training, please contact the Chairman of the BHSD Training Committee, Patsy Romero, at 505-473-0334.

3. Press ENTER for next slide. 3 Clinical Documentation Covered in entire training: Assessment (covered here) Treatment Planning Progress Notes Discharge Summary

4. Press ENTER for next slide. 4 The ASSESSMENT

5. Press ENTER for next slide. 5 What is the assessment? An ASSESSMENT is the gathering of relevant information about the consumer, their environment, their problem(s), and what they hope to accomplish through the therapeutic intervention.

6. Press ENTER for next slide. 6 The Assessment should answer these basic questions. For what problems is the consumer seeking treatment? How have these problems affected the consumer�s life? What is maintaining these problems? What does the consumer hope to gain from treatment?

7. Press ENTER for next slide. 7 What are the goals of the Assessment? The assessment should enable both the Consumer and Clinician to answer the following questions: Is treatment of any kind required? If treatment is indicated, what are the relative merits of the intervention? What types of treatment approaches might be appropriate? What is the depth of therapy needed? Who should the therapy involve? Have cultural issues been considered?

8. Press ENTER for next slide. 8 Who can conduct an Assessment? Assessments should be conducted by qualified personnel who: Is knowledge to assess the specific needs of the consumer being served; Are trained in the use of applicable and appropriate tools; and, Are culturally sensitive to the consumer�s needs.

9. Press ENTER for next slide. 9 What should the Assessment include? Presenting Problem or Chief Complaint History of the Problem Family and Social History Educational History Vocational / Employment History Mental Health and Substance Abuse History Medical History Consumer Strengths Nutritional Assessment Chronic Pain Assessment

10. Press ENTER for next slide. 10 What should the Assessment include? Important Consumer Characteristics: Functional Impairment; Subjective Distress; Problem Complexity; Readiness to Change; Potential to resist therapeutic influences; Social Supports; Coping Styles; Mental Status Evaluation Risk of Harm to Self and or Others Diagnosis and related considerations Treatment Goals Motivation to Change Documentation of Cultural Needs

11. Press ENTER for next slide. 11 What should the Assessment include? Screening for cigarettes and over-the-counter medications Housing Needs Legal Status Known allergies and or sensitivities to pharmaceuticals The name and amount of any prescribed medications

12. Press ENTER for next slide. 12 Presenting Problem or Chief Compliant Answers the questions: What brings you here today? Why do you think you need treatment? The answers provide immediate insight into what the consumer considers the most pressing problem and provides clues as to how distressing these problems are. If the consumer is entering treatment voluntarily, information relating to how motivated the consumer is for treatment, and their expectations for treatment can also be obtained. Consumer responses to these questions should be recorded verbatim.

13. Press ENTER for next slide. 13 History of the Problem Thorough knowledge and understanding of the problems history can greatly facilitate its treatment. Your documentation should include the following: When the consumer began experiencing the problem, Their perception of the cause of the problem, Significant events that occurred at or the time the problem began Precipitants of the problem, What maintains the problems presence, The problem�s course over time, How the problem effects the consumers ability to function, What the consumer has done to try to deal with the problem.

14. Press ENTER for next slide. 14 Family History Helps you understand how the consumer got to this point through a familial context. Important aspects of the family history include: The occupation and education of patents, The number of siblings and their birth order, The quality of consumers relationship to parents and or siblings Significant extended family members, Parental approach to child rearing, Familial expectations for the consumer.

15. Press ENTER for next slide. 15 Social History Helps you understand how the consumer got to this point through a social context. It may also provide you with information relating to the consumers ability to relate well with and take directions from perceived authority figures. Important information includes: the general number of and types of friendships; participation in team sports; involvement in clubs or other social activities; being a leader vs. a follower; involvement in religion, political or gang activities, and other opportunities requiring interpersonal interactions. The consumer�s experiences stemming from being a member of a racial or ethnic minority, which can have a significant bearing on their current problem and coping styles.

16. Press ENTER for next slide. 16 Educational History This generally provides limited yet potentially important information. The attained level of education can give you an rough estimate of the consumer�s level of intelligence. It also speaks to the consumer�s aspirations, goals, ability to gain from learning experiences, their willingness to make a commitment, their amount of perseverance, and their ability to delay gratification.

17. Press ENTER for next slide. 17 Vocational / Employment History This can provide you with a wealth of information that can be useful in understanding the consumer and developing an effective treatment plan. Interactions with supervisors and peers can provide you with insights into the consumer�s ability to get along with others and take direction. In addition, the consumer�s ability to assume and meet the expectations of being a hired employee may have implications for assuming the role of a consumer and complying with treatment recommendations.

18. Press ENTER for next slide. 18 Mental Health and Substance Abuse History A previous history of behavioral health problems and treatment is important to know. This should be documented regardless of the level of care. Obtaining this information can shed light on whether the current problem is part of a single or recurrent episode, or a progression of behavioral health problems over a period of time, what treatment approaches have or have not worked in the past, and the consumer�s willingness to engage in the treatment process. Consumers seeking treatment for mental health problems might not always know that they have an accompanying substance abuse problem, or vise versa.

19. Press ENTER for next slide. 19 Substance Abuse History: Questions to Ask Consumers Inquiry into patterns of substance use should include the following: Substances used in the past, including prescribed drugs. Substances used recently, especially those used within the last 48 hours. Substances of preference. Frequency with which each substance is used. Previous occurrences of overdose, withdrawal, or adverse drug or alcohol reactions. History of previous substance abuse treatment received. Year or Age of first use of each substance.

20. Press ENTER for next slide. 20 Medical History At a minimum, you should document any significant illnesses, hospitalizations, past and current physical illnesses or conditions (i.e., breast or prostate cancer, diabetes, hypertension), injuries or disorders affecting the central nervous system, any functional limitations. This information can provide clues to the presenting symptomatology, functioning, and suggest the need for referral to a psychiatrist or other medical professional for evaluation, treatment, and or management. You should include a cursory family history of significant medical problems.

21. Press ENTER for next slide. 21 Consumer Strengths It is important to recognize that the benefits of assessing consumer strengths go beyond their value to the development of the treatment plan. They force consumers to consider that their psychological assets can have therapeutic value(s) in themselves. In essence, strength-based assessments can serve as an intervention before formal treatment actually begins. They can help build self-esteem and self-confidence, reinforce the consumers� efforts to seek help, and increase their motivation to return to engage in the work of treatment.

22. Press ENTER for next slide. 22 Nutritional Assessment Nutritional Assessment should include questions regarding quality and quantity of food. Question can be as simple as �Do you get enough to eat on a regular basis?�.

23. Press ENTER for next slide. 23 Pain Assessment Each clinician should explore the existence and, if so, the nature and intensity of any pain experienced The results of the inquiry should be documented in a way that facilitates regular reassessment and follow-up; There should be documentation of: Education to the Consumer and their families about effective pain management; and Address consumer needs for symptom management in the discharge planning process.

24. Press ENTER for next slide. 24 Important Consumer Characteristics It should be obvious that the assessment for the purpose of treatment planning should go beyond the identification and description of the consumer�s symptoms or problems. The consumer�s family, social, psychiatric, medical, educational, legal, and employment histories provide a wealth of information for understanding the origin, development, and maintenance of their behavioral health problem(s). At the same time, other types of information can be quite useful in developing a treatment plan.

25. Press ENTER for next slide. 25 Important Consumer Characteristics:Functional Impairment The degree to which behavioral health consumers are impaired in their social, environmental and interpersonal functioning has been identified a one of the most important factors to consider during an assessment. Not only is social functioning information important for treatment planning and outcomes assessment, it is also critical for arriving at the Global Assessment of Functioning (GAF) rating for Axis V.

26. Press ENTER for next slide. 26 Clinical Indicators of Functional Impairment These impairments can be exhibited or reported during the assessment: Problem interferes with the consumer�s functioning during the assessment. Consumer cannot concentrate on interview tasks. Consumer is distracted even by minor events. Consumer appears incapacitated by the problem and has difficulty in functioning. Consumer has difficulty in interacting with the interviewer as a result of problem severity. Multiple areas of performance are impaired in daily life.

27. Press ENTER for next slide. 27 Important Consumer Characteristics: Subjective Distress Subjective distress essentially refers to the �state� phenomenon; however, an assessment of the consumer�s �trait� level of distress may also yield information important to the treatment planning process.

28. Press ENTER for next slide. 28 Clinical Indicators of Subjective Distress The following high distress indicators may be exhibited or reported during the assessment: High emotional arousal High symptomatic distress Motor agitation Difficulty in maintaining concentration Unsteady, faltering voice Autonomic symptoms Hyper-vigilance Excited affect Intense feelings

29. Press ENTER for next slide. 29 Clinical Indicators of Subjective Distress The following low distress indicators may be exhibited or reported during the assessment: Decreased emotional arousal Decreased symptomatic distress Reduced motor activity Decreased investment in treatment Low energy level Blunted or constricted affect Un-modulated verbalization Slow verbalizations

30. Press ENTER for next slide. 30 Important Consumer Characteristics: Problem Complexity Whether the consumer�s presenting problems are high or low with respect to complexity can have an important bearing on the treatment planning process. Ascertaining the level of problem complexity can be facilitated by historical information about other aspects of the consumers life. The historical information can allow for the revelation of �recurrent patterns or themes arising within objectively different but symbolically related relationships�.

31. Press ENTER for next slide. 31 Clinical Indicators of Problem Complexities: Non-Complex Problems The following may be exhibited or reported during the assessment: Chronic habits and or transient responses Behavior repetition is maintained by inadequate knowledge or by ongoing situational rewards Behaviors have a direct relationship to initiating events Behaviors are situation specific

32. Press ENTER for next slide. 32 Clinical Indicators of Problem Complexities: Complex Problems The following may be exhibited or reported during the assessment: Behaviors are repeated as themes across unrelated or dissimilar situations Behaviors are ritualized (yet self-defeating) attempts to resolve dynamic or interpersonal conflicts Current conflicts are expressions of the consumer�s past rather than present relationships Repetitive behaviors results in suffering rather than gratification Symptoms have a symbolic relationship to initiating events Problems are enduring, repetitive and symbolic manifestations of characterological conflicts

33. Press ENTER for next slide. 33 Important Consumer Characteristics:Readiness to Change The importance of the consumer�s readiness to change in the therapeutic process comes from the work of Prochaska, DiClemente and their colleagues. They have identified five stages through which individuals go when changing various aspects of their lives. These changes apply not only to change that is sought by behavioral health treatment, but also in non-therapeutic contexts. The five stages are: Pre-Contemplative, Contemplative, Preparation, Action and Maintenance.

34. Press ENTER for next slide. 34 Prochaska�s Stages of Change:Pre-contemplative Little or no awareness of problems, little or no serious consideration or intent to change, often presents for treatment at the request of or pressure from another party, change may be exhibited when pressure is applied but the consumer reverts to previous behavior(s) when pressure is removed. Resistant to recognizing or changing the problem is the hallmark of the pre-contemplative stage.

35. Press ENTER for next slide. 35 Prochaska�s Stages of Change:Contemplative Awareness of problem and serious thoughts about working on it, but no commitment to begin to work on it, weighing pros and cons of the problem and its solution. Serious consideration of problem resolution is the hallmark of the contemplation stage.

36. Press ENTER for next slide. 36 Prochaska�s Stages of Change:Preparation Intention to take serious, effective action in the near future (e.g., within a month) but has already made small behavioral changes. Decision making is the hallmark of this stage.

37. Press ENTER for next slide. 37 Prochaska�s Stages of Change:Action Overt modification of behavior, experiences or environment in an effort to overcome the problem. Modification of problem behavior to an acceptable criterion and serious efforts to change are the hallmarks of this stage.

38. Press ENTER for next slide. 38 Prochaska�s Stages of Change:Maintenance Continuation of change to prevent relapse and consolidate the gains made during the action stage. Stabilizing behavior change and avoiding relapse are the hallmarks of this stage.

39. Press ENTER for next slide. 39 Important Consumer Characteristics:Potential Resistance to Therapeutic Influences The potential resistance to therapeutic influences may be an indicator of the consumers motivation to engage in treatment. Two different types of resistance exists: Resistance, which may be considered a state-like quality in which consumers fail to comply with external recommendations or directions Reactance, a more extreme trait-like form of resistance that stems from the consumers feelings that their freedom or sense of control is being challenged by outside forces. This is manifested as active opposition.

40. Press ENTER for next slide. 40 Important Consumer Characteristics: Social Supports Documentation of social supports the consumers perception of potential sources of psychological and physical support that they can draw upon during and after treatment. Should be examined from both the objective and subjective perspectives.

41. Press ENTER for next slide. 41 Social Supports: Objective Perspective Objective social supports can be assessed from external evidence of resources available to the consumer, such as marriage, physical proximity to relatives, network of identified friends, membership in organizations and involvement in religious activities.

42. Press ENTER for next slide. 42 Social Supports: Subjective Perspective Subjective social supports refers to the reported quality of the consumer�s social relationships.

43. Press ENTER for next slide. 43 Important Consumer Characteristics: Coping Styles An important consideration for treatment planning is the identification of the consumer�s coping style. Coping style is defined as �an enduring trait that relates to the way one copes with personal or interpersonal threats�. There are two identified coping styles: internalization and externalization.

44. Press ENTER for next slide. 44 Coping Style: Internalization This style of coping is suggested in consumers who tend to: Avoid, deny, repress or compartmentalize sources of anxiety; Be overly introverted, introspective, self-critical, and self-controlled; Be emotionally constricted.

45. Press ENTER for next slide. 45 Undoing Self-punishment Intellectualization Isolation of affect Emotional over-control or constriction Low tolerance for feelings or sensations High resistance for feelings or sensations Denial Reversal Reaction formation Repression Minimization Unrecognized wishes or desires Introversion Social withdrawal Somatization (autonomic nervous system symptoms) Coping Style: Internalization Clinical Indicators

46. Press ENTER for next slide. 46 Coping Style: Externalization This style of coping is suggested in consumers who tend to: Directly avoid, rationalize, project or act-out onto their environment(s); Exhibit a degree of insensitivity to their own and others� feelings; Be spontaneous, impulsive, extraverted, and sometimes manipulative.

47. Press ENTER for next slide. 47 Ambivalence Acting Out Blaming others and self Low tolerance for frustration Difficulty in differentiating emotions Avoidance or escape (or both) Projection Conversation symptoms Paranoid reactions Unsocialized aggression Manipulation of others Ego-syntonic behaviors Extraversion Somatization (seeking of secondary gain via physical symptoms) Coping Style: Externalization Clinical Indicators

48. Press ENTER for next slide. 48 Mental Status Examination Any clinical assessment should include a mental status examination (MSE). This information comes from the clinician�s observations of and impressions formed during the course of the clinical interview and as a result of other assessment procedures. Some aspects of the MSE usually require specific questioning that typically would not be included during the other parts of the assessment. The MSE generally addresses a number of general categories or aspects of the consumer�s functioning, including descriptions of their appearance and behavior, mood and affect, perception, thought processes, orientation, memory, judgment, and insight.

49. Press ENTER for next slide. 49 MSE Outline Appearance (level of arousal, attentiveness, age, position, posture, attire, grooming, eye contact, physical characteristics, facial expression) Activity (movement, tremor, choreoathetoid movements, dystonias, automatic movements, tics, mannerisms, compulsions, other motor abnormalities or expressions) Attitude toward to clinician Mood (euthymic, angry, euphoric, apathetic, dysphoric, apprehensive) Affect (appropriateness, intensity, mobility, range, reactivity) Speech and Language (fluency, repetition, comprehension, naming, writing, reading, prosody, quality of speech) Thought Process (circumstantiability, flight of ideas, loose association, tangentiality, clang associations, echolalia, neologims, perserveration, though blocking)

50. Press ENTER for next slide. 50 MSE Outline Thought Content (delusion, homicidal or suicidal ideation, magical thinking, obsession, rumination, preoccupation, overvalued idea, paranoia, phobia, poverty of speech, suspiciousness) Perception (autoscopy, d�j� vu, depersonalization, hallucination, illusion, jamais vu) Cognition (orientation, attention, concentration, immediate recall, short-term memory, long-term memory, constructional ability, abstraction, conceptualization) Insight Judgment Defense Mechanisms (altruism, humor, suppression, repression, displacement, dissociation, reaction formation, intellectualization, splitting, externalization, projection, acting out, denial, distortion)

51. Press ENTER for next slide. 51 Risk of Harm to Self or Others Assessment of suicidal or homicidal ideation and potential should always be assessed, even if it consists of no more than asking the question �Have you been having thoughts of harming yourself or others?� If the consumer answers yes, you should inquire further, asking about how long the consumer has been having these thoughts, how frequently do they occur, previous and or current plans or attempts, and opportunities to act on these thoughts. The presence of any given risk factor should always be considered in light of all available information about the consumer.

52. Press ENTER for next slide. 52 Examples of Commonly Identified Suicide Risk Factors Male Caucasian Over 45 years old Unmarried History of previous suicide attempt Presence of a mental disorder, especially an affective disorder Current state of distress Poor impulse control Co-morbid physical problems Recent job, financial, or other loss Clues given at admission to suicidal ideation, intent or plan

53. Press ENTER for next slide. 53 Examples of Commonly Identified Homicide Risk Factors Alcohol and readily accessible firearms are major factors in homicides. Other factors such as drug use, poverty or unemployment, racial discrimination, cultural attitudes, belief in male dominance, and even poor communication and problem-solving skills can also put persons at higher risk of being a homicide victim or offender.

54. Press ENTER for next slide. 54 Diagnosis and Related Considerations An accurate diagnosis can have important implications in the development of an effective course of treatment. A diagnosis of schizophrenia or major depressive disorder by itself would suggest that adjunctive psychopharmacological intervention should be considered. Identification of a personality disorder on Axis II with or without an accompanying Axis I disorder would have a bearing on the projected length of treatment. Diagnoses are efficient tools for communicating among professionals and organizations.

55. Press ENTER for next slide. 55 DSM-IV Multi-axial Diagnostic System Axis I (Clinical Disorders, other conditions that may be a focus of attention) Examples: Anxiety disorders, mood disorders, schizophrenia, alcohol abuse, substance abuse Axis II (Personality disorders, mental retardation) Examples: Antisocial personality disorder, avoidant personality disorder, mental retardation Axis III (General medical conditions) Examples: Cancer, Hypertension, Diabetes, Migraines, Chronic Pain, Injuries Axis IV (Psychosocial and environmental problems) Examples: Problems with primary support group, occupational problems, problems relating to social environment Axis V (Global assessment of functioning) Example: GAF Score

56. Press ENTER for next slide. 56 Treatment Goals No assessment would be complete without the identification of treatment goals. In some cases, one or two goals might be identified, in others, several goals might be identified and prioritized by the importance and immediacy of the goal. Goals can be consumer-identified or third-party goals. To assist in clarifying and setting goals, it is important to have consumers identify what the anticipated or hoped-for results of achieving their goals will be.

57. Press ENTER for next slide. 57 Treatment Goals:Consumer-Identified Goals In most cases, these are the most obvious goals. It was the amelioration of the unwanted behavior or other symptoms that led the consumer to seek treatment, which is their goal. Directly ask the consumer directly what their goals are using these three questions: What do you see as our biggest problem? What do you want to be different about your life at the end of your treatment? Does this goal involve changing things about yourself?

58. Press ENTER for next slide. 58 Consumer Identified Goals: Does this goal involve changing things about yourself? By asking the above question, it forces the consumer to think through their problems and realize the extent to which these problems have control over their thoughts, feelings, and behavior(s). It can provide a means for consumers to gain insight into their problems � a therapeutic goal in and of itself.

59. Press ENTER for next slide. 59 Consumer-Identified Goals It is suggested that clinicians ask consumers the following questions relating to establishing objective outcome criteria for goal achievement: How will you know when things are different? What kinds of things will you be doing differently? What negative things will no longer be present? What positive things will you be doing? These questions offer consumers an opportunity to gain insight into their problems. Through clinician feedback consumers can be helped to see how realistic their expectations are for treatment and determine whether those expectations should be modified.

60. Press ENTER for next slide. 60 Treatment goals set by non-consumer stakeholders in the treatment process must always be considered. These stakeholders can be spouses, the judicial system, the employer, or other family members. As with consumer-identified goals, the third parties expectations for the outcomes of goal achievement should be sought, and they may also be modified based on the clinician�s evaluation of how realistic they are. Treatment Goals:Third Party Goals

61. Press ENTER for next slide. 61 Motivation to Change An important factor to assess for treatment planning is the consumer�s motivation to change. How to arrive at a good estimate of the consumers level of motivation to change: Is the consumer seeking treatment from their own desire for help or from the request/demand of another? What is the consumer�s stated willingness to be actively involved in the treatment process? What is the consumer�s subjective distress and reactance? What is the consumer�s readiness for, or stage of change?

62. Press ENTER for next slide. 62 Motivation to Change Seven factors have been identified that should be considered in the evaluation of motivation to engage in treatment: A willingness to participate in the diagnostic evaluation. Honesty in reporting about oneself and one�s difficulties. Ability to recognize that the symptoms experienced are psychological in nature. Introspectiveness and curiosity about one�s own behavior and motives. Openness to new ideas, with a willingness to consider different attitudes. Realistic expectations for the results of treatment. Willingness to make a reasonable sacrifice in order to achieve a successful outcome.

63. Press ENTER for next slide. 63 Cultural Issues A critical component of the assessment is the addressing of cultural needs. Using culturally appropriate interventions can lead to better outcomes for consumers. A simple working definition of the concept of culture is that it is a shared set of beliefs, norms, and values in which language is a key factor. Other factors that play an important role include ethnicity, race, sexual orientation, disability, and other self-defined characteristics.

64. Press ENTER for next slide. 64 It is important to remember that culture is not fixed or frozen in time, but rather exists in a constant state of change that is learned, taught, and reproduced. A framework for considering human diversity can be thought of using the ADDRESSING pneumonic, and includes the following factors: Cultural Issues

65. Press ENTER for next slide. 65 Cultural Issues Age and generational influences Developmental and acquired Disabilities Religion and spiritual orientation Ethnicity Socioeconomic status Sexual Orientation Indigenous heritage National origin Gender

66. Press ENTER for next slide. 66 Issues of culture, ethnicity, race, and other attributes which individuals use to self-identify impact the quality of interactions with providers and thus the assessment. Cultural tradition, experience and bias, both by the consumer as well as the therapist, are all part of an unstated but powerful dynamic in the helping relationship that impacts how information is provided and received. Cultural Issues

67. Press ENTER for next slide. 67 The assessment must consider how culture and social contexts shape the consumer�s symptoms, presentation, and meaning, as well as coping styles, family influences, attitudes towards help, and a willingness to trust helping professionals are all influenced by the consumer�s culture. The relationship between the therapist, the consumer, and their family are potentially shaped by differences in culture and social status. Your efforts at assessing the consumers needs are impacted by factors including styles of communication, capacity for rapport, comfort with disclosure, the perception of safety and privacy, and the experience of power, dignity, and respect, all of which, to a degree, are culturally determined. Cultural Issues

68. Press ENTER for next slide. 68 The impact of a number of other cultural issues, such as acculturation and immigration stress, identity, racism, marginalization, or discrimination, all affect help-seeking and successful engagement and must be considered. Issues of assimilation, alienation, and co-occurring trauma can also affect the experience of seeking and receiving treatment. Cultural Issues

69. Press ENTER for next slide. 69 Screening for Cigarette and Over-the-Counter Medications When assessing the consumer�s use of illegal substances, the consumer should also be questioned regarding their use of cigarettes and other over-the-counter medications that may have an effect on the consumer.

70. Press ENTER for next slide. 70 Housing Needs An important element in the treatment and assessment process is the determination of the consumer�s current housing situation and housing needs. This may be one of the primary barriers to treatment, especially if the consumer is homeless or living in unsafe or unsanitary conditions.

71. Press ENTER for next slide. 71 Legal Status Another barrier to treatment is the consumer�s involvement in the legal system. This involvement could hinder participation in residential treatment programs, especially if the consumer must leave the program for court or other legal related appointments. Additionally, there may be specific treatment requirements imposed by the legal system.

72. Press ENTER for next slide. 72 Known Allergies and or Sensitivities to Pharmaceuticals It is important to know if your consumer has any allergies or sensitivities, document this information, and update it as appropriate. If there are no known allergies or sensitivities, �NKDA� should be documented to indicate no known drug allergies.

73. Press ENTER for next slide. 73 The Name and Amount of any Prescribed Medications It is important to the assessment and the treatment process to know what types of medications your consumers may be taking. These medications could have side effects that affect their mood or affect. In addition, these medications may be counter-indicated for medications that may be prescribed by your agency. This information should be updated as appropriate.

74. Press ENTER for next slide. 74 Assessment Summary The goal of developing a useful and effective treatment plan can be achieved only through a good assessment. The manner and form of the assessment will vary for clinician to clinician, and from clinic to clinic. The focal areas or content of the assessment include the nature and history of the consumers presenting problem, as well as other historical information important to understanding the problem�s development, maintenance, and effects on the consumer�s current functioning. This includes the consumer�s medical and behavioral health history.

75. Press ENTER for next slide. 75 Assessment Summary Information regarding the other consumer characteristics is also important to know for creating the treatment plan. The consumer�s strengths or assets can be used to effect change, to motive them to engage in the therapeutic relationship, and to work to effect change(s) in their lives. Information obtained from the MSE and assessment of the consumer�s risk or harm to self or others can assist in determining various aspects of care, including the appropriate level of care.

76. Press ENTER for next slide. 76 Assessment Summary The results of the MSE can also be used to assign a diagnosis to the consumer. No assessment would be complete without the therapist and consumer knowing the desired goals of treatment.

77. Press ENTER for next slide. 77 Assessment Summary Providing an emotionally safe environment for disclosure and to allay the fears, anxieties, and preconceptions of those seeking help is critical to success in assessment. Knowledge about other cultures, awareness of one�s own limits, and willingness to seek help and consultation when necessary are also key ingredients for success.

78. Press ENTER for next slide. 78 Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test. According to this training, which of the following qualifications must a professional have to conduct an assessment? A LADAC Licensure The knowledge to assess the specific needs of the consumer being served and trained in the use of applicable and appropriate tools Three years of experience in the agency A bachelors degree All of the above Which of the following were not included as part of the assessment? Presenting Problem or Chief Complaint Educational History Vocational / Employment History Political Views Mental Health and Substance Abuse History

79. Press ENTER for next slide. 79 Which of the following were not included as part of the assessment? Medical History Consumer Strengths Nutritional Assessment Credit History Risk of Harm to Self or Others Which of the following statements regarding how to conduct the assessment of the chief complaint / presenting problem is false? If a consumer is entering treatment voluntarily, information should be gathered relating to how motivated the consumer is for treatment. It is important to get insight into what the consumer thinks is the most pressing problem. It is not wise to write down verbatim the consumer�s answer to questions about the presenting problem / chief complaint. If a consumer is entering treatment voluntarily, information can be gathered relating to their expectations for treatment. A good way to approach the question is to ask, �What brings you here today?� Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

80. Press ENTER for next slide. 80 Obtaining educational history is useful for which of the following reasons? It gives a rough estimate of the consumer�s level of intelligence. It speaks to the consumer�s aspirations and / or goals. It helps them to understand their learning style and preference for verbal, aural or kinesthetic learning. It speaks to the consumer�s ability to gain from learning experiences, their willingness to make a commitment, their amount of perseverance, and their ability to delay gratification. A and C above. In order to perform a culturally competent assessment, in which of the following parts of an assessment should the cultural context of a consumer�s life be taken into account? Medical History Educational History Nutritional Assessment Consumer Strengths All of the above Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

81. Press ENTER for next slide. 81 Assessing consumer strengths (strength-based assessments) are important for which of the following reasons? It enhances consumer�s consideration that their psychological assets can have therapeutic value(s) in themselves. It can serve as an intervention before the formal treatment actually begins. It can help build self-esteem and self-confidence, and reinforce the consumers� efforts to seek help. It can increase the consumer�s motivation to return to engage in the work of treatment. All of the above Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

82. Press ENTER for next slide. 82 The Global Assessment of Functioning (GAF) rating for Axis V can be ascertained by which of the following? Family History Pain Assessment Nutritional Assessment Social Functioning Information Presenting Problem Which of the following are low distress indicators which may be exhibited or reported during the assessment? Motor agitation Difficulty in maintaining concentration Unsteady, faltering voice Blunted or constricted affect High emotional arousal Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

83. Press ENTER for next slide. 83 Which of the following are high distress indicators which may be exhibited or reported during the assessment? Motor agitation Reduced motor activity Decreased investment in treatment Low energy level Blunted or constricted affect Which of the following are not Clinical Indicators of Complex Problems? Behaviors are repeated as themes across unrelated or dissimilar situations Behaviors are ritualized (yet self-defeating) attempts to resolve dynamic or interpersonal conflicts Behaviors are situation specific Repetitive behaviors result in suffering rather than gratification Problems are enduring, repetitive and symbolic manifestations of characterological conflicts Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

84. Press ENTER for next slide. 84 Which of the following are not one of Prochaska, DiClemente et al�s five stages of change? Pre-Contemplative Contemplative Denial Preparation Action Which of the following is a type of Important Consumer Characteristics of Potential Resistance to Therapeutic Influences? Resistance, which may be considered a state-like quality in which consumers fail to comply with external recommendations or directions. Sublimation, which may be considered a state like quality in which consumers direct their non-integrated unconscious feelings into their present day functioning. Reactance, a more extreme trait-like form of resistance that stems from the consumers feelings that their freedom or sense of control is being challenged by outside forces. This is manifested as active opposition. Denial, which may be considered a trait like quality in which consumers are unable to confront realities of their life form deep seated fear of annihilation. A and B above. Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

85. Press ENTER for next slide. 85 Which of the following are coping styles? Denial Reversal Reaction Formation Repression All of the above If you are conducting a culturally competent assessment, which of the following are important coping styles to understand in the context of a person�s cultural background? Intellectualization Isolation of Affect Emotional over-control or constriction Low tolerance for feelings or sensations All of the above Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

86. Press ENTER for next slide. 86 Which of the following are not commonly identified risk factors? History of previous suicide attempt Poor impulse control Married for over 20 years Co-morbid physical problems Recent job, financial, or other loss Which of the following is mismatched? Axis I (Clinical Disorders, other conditions that may be a focus of attention) Examples: Anxiety Disorders, Mood Disorders, Schizophrenia, Alcohol Abuse, Substance Abuse Axis II (Personality Disorders, Mental Retardation) Examples: Antisocial Personality Disorder, Avoidant Personality Disorder, Mental Retardation Axis III (General Medical Conditions) Examples: Cancer, Hypertension, Diabetes, Migraines, Chronic Pain, Injuries Axis IV (Alcohol or Drug Abuse in Remission) Axis V (Global Assessment of Functioning) Examples: GAF Score Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

87. Press ENTER for next slide. 87 Which of the following questions is not generally asked of consumers related to establishing objective outcome criteria for goal achievement? How will you know when things are different? What kinds of things will you be doing differently? What negative things will no longer be present? What positive things will you be doing? All of the above Which of the following Motivation to Change factors have been identified that should be considered in the evaluation of motivation to engage in treatment? A willingness to participate in the diagnostic evaluation Ability to recognize that the symptoms experienced are psychological in nature. Willingness not to change any relationships in their lives in their first year of sobriety. Openness to new ideas, with a willingness to consider different attitudes. Realistic expectations for the results of treatment. Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

88. Press ENTER for next slide. 88 Which of the following are issues to address in the assessment in terms of a consumers culture? Age and generational influences Development and acquired Disabilities Religion and spiritual orientation Indigenous heritage All of the above A simple working definition of the concept of culture is that it is a shared set of beliefs, norms, and values in which language is a key factor. Which of the following factors play an important role in the assessment of the concept of culture for the consumer who is being evaluated? Ethnicity Race Sexual Orientation Disability All of the above Assessment Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

89. Press ENTER for next slide. 89 Sources Used: Maruish, Mark E. Essentials of Treatment Planning. New York: John Wiley & Sons, Inc, 2002. Department of Consumer and Industry Services, Bureau of Health Systems. Administrative Rules for Substance Abuse Service Programs, Part 8: Inpatient Programs. http://www.michigan.gov/documents/cis_bhs_fhs_sa_part8_37167_7.pdf Addressing Violence in Oklahoma. http://www.health.state.ok.us/program/injury/violence/homicide.html Adams, Neal and Diane M. Grieder. Treatment Planning for Person-Centered Care. New York: Elsevier Academic Press, 2005.

90. Press ENTER for next slide. 90 Sources Used: Gilman, Peter B, PhD. A New Era of Documentation in Psychiatry: Advice on Psychotherapy Progress Notes. Behavioral Healthcare Tomorrow, February 2004. Bowden, Kirk MA, CPC. Clinical Documentation and Case Report Writing. Arizona: Rio Salado College, 1999. UTHCPC Procedures: Elements of the Discharge Summary. http://www.uth.tmc.edu/uth_orgs/hcpc/procedures/volume2/chapter4/discharge-04.htm

91. Press ENTER for next slide. 91 Thank You The BHSD Training Committee would like to thank the following individuals for their hard work in creating this training: David Wood, Ph.D., Quality Management Director, Region 2 Behavioral Health Providers, Inc. Celinda Levy, Ph.D., MBA, CSUD, CPHQ, Hospital AdministratorTurquoise Lodge Patsy Romero, Executive Direction, Region 2 Behavioral Health Providers, Inc. Barbara Kashinski, CPHQ, Quality Management Director, Region 5 Regional Care Coordinator / Aspen Behavioral Health