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 one of four trainings. 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 this training: Assessment Treatment Planning Progress Notes Discharge Summary (covered here)

4. Press ENTER for next slide. 4 Discharge Summary

5. Press ENTER for next slide. 5 Discharge Summary Although discharge planning begins at the time of intake, a discharge summary must be documented within 30 days of the consumer leaving or being terminated from the treatment program.

6. Press ENTER for next slide. 6 Discharge Summary Elements Consumer Name, chart number, date of birth or age, date admitted to the program and date discharged from the program Reason for therapy Services received by the consumer Initial Diagnosis Course of Treatment Goals of Therapy Discharge Diagnosis Discharge and Aftercare Plan Listing of any referrals made Prognosis Condition upon discharge Signature of author, including credentials

7. Press ENTER for next slide. 7 Discharge Summary Elements:Reason for Therapy This section should answer the question “Why was the consumer receiving therapeutic services?” Example: Reason for Therapy: Consumer was unable to gain sobriety on his own from cocaine.

8. Press ENTER for next slide. 8 Discharge Summary Elements: Services received by the consumer Use the section of the discharge plan to list the types of services that the consumer received while in therapy. Example: Treatment Services Provided: Client received outpatient individual, group and IOP for cocaine dependence.

9. Press ENTER for next slide. 9 Use this section to document your initial assessment diagnoses, as these may change through the treatment episode. Example: Initial Diagnosis: Cocaine Dependency 304.20, and rule out Major Depressive Disorder 296.32 Discharge Summary Elements: Initial Diagnosis

10. Press ENTER for next slide. 10 Use this section to document what brought the consumer to therapy and how they progressed through the therapeutic process. Example (Continued next slide): Course of Treatment: The client had an accident at work which required a mandatory drug screen; the client tested positive for cocaine. He was placed on a leave of absence without pay and he cannot return to work until he has completed a drug treatment program. At intake, the client reported a willingness to enter treatment. Discharge Summary Elements: Course of Treatment

11. Press ENTER for next slide. 11 Discharge Summary Elements: Course of Treatment The client reported that he first smoked marijuana and used alcohol at age 13. He continued using marijuana and alcohol through high school and college. The client reported that drugs did not become a problem for him until he began using cocaine at age 23. The client received 7 days of detox at the Mesa Valley Clinic and attend 6 weeks of IOP at this clinic. The client was able to remain clean and after 6 weeks graduated from IOP to outpatient individual and group therapy. After an additional 6 weeks of group and individual therapy, client has finished treatment, is maintaining sobriety and has returned to work. The client was noted to have depression and panic attacks as co-occurring issues. The client was referred to Sun Valley Clinic for treatment of these issues.

12. Press ENTER for next slide. 12 Use this section to summarize the clients long-term goals. Example: Treatment Plan Goals: Client will gain long-term sobriety from drugs and alcohol. Client will make involvement in Cocaine Anonymous a part of his way of life. Client will continue treatment a Sun Valley Clinic for depression and panic attacks. Discharge Summary Elements: Goals of Therapy

13. Press ENTER for next slide. 13 Discharge Summary Elements: Discharge Diagnosis Use this section to document the final diagnosis of the consumer. Example: Diagnosis at Discharge: Cocaine Dependency 304.20, Major Depressive Disorder 296.32.

14. Press ENTER for next slide. 14 Use this section to summarize the discharge planning done for this client and their aftercare plan, for maintaining the goals accomplished during treatment. Example: Discharge and Aftercare Plan: The client did not complete the treatment program; he relapsed one week before graduation from the program, then did not return to treatment. This writer has been unable to contact the client despite numerous phone calls and letters to the client. Client should continue attending Cocaine Anonymous meetings. Client should return to treatment whenever appropriate. Discharge Summary Elements: Discharge and Aftercare Plan

15. Press ENTER for next slide. 15 Discharge Summary Elements: Listing of Referrals Made Use this section to document any referrals made on behalf of the client. Example: Referrals: The client was referred to Sun Valley Clinic for treatment of depression.

16. Press ENTER for next slide. 16 Use this section to document the client’s prognosis. Example: Prognosis: The prognosis is poor unless the client returns to treatment and becomes active in a 12-step program with a sponsor. Prognosis: The prognosis is good for this client. He successfully completed 6 weeks of IOP and 6 weeks of outpatient group and individual treatment. In addition, the client has a sponsor through Alcoholics Anonymous and attends 3 meetings a week. Discharge Summary Elements: Prognosis

17. Press ENTER for next slide. 17 Use this section to document the client’s condition on the day of discharge from the program. You can use this section to compare the client today versus the client on the day of admission to the program. Example: Condition upon Discharge: The client made minimal improvement. The client was actively using cocaine when he last attended the group session. He was not active in the recommend 12-step program. Condition upon Discharge: The client made great improvement. The client remained clean through-out treatment and attended graduation ceremonies from the program. Discharge Summary Elements: Condition upon Discharge

18. Press ENTER for next slide. 18 Discharge Summary Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test. Discharge planning should begin at the time of intake. At what point should the discharge summary be completed? Prior to the time the consumer enters treatment. Within 24 hours of the consumer leaving or being terminated from the treatment program. Within 30 days of the consumer leaving or being terminated from the treatment program. Within 60 days of the consumer leaving or being terminated from the program. Within 120 days of the consumer leaving or being terminated from the treatment program. Which of the following items is NOT recommended as an element of the discharge summary? A listing of topics discussed by the client during treatment. Reason for therapy. Services received by the consumer. Course of treatment. Listing of any referrals made.

19. Press ENTER for next slide. 19 Which of the following is the central purpose of describing the clients condition upon discharge? To list the services that the client has received. To clarify the treatment plan goals. To review the referrals made on behalf of the client. To document the client’s progress. To compare the client today versus the client on the day of admission to this program. Discharge Summary Test Questions:Please record the question number and answer on a separate piece of paper or use the provided test.

20. Press ENTER for next slide. 20 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.

21. Press ENTER for next slide. 21 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

22. Press ENTER for next slide. 22 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