Enhancing Interpretive Summary Writing Skills for Clinicians

1. How to Write Meaningful Interpretive SummariesUpdated 7/09 for CDS Staff A CDCMHC/Quality Improvement Dept. Version 7/04

2. Interpretive Summary Training 2 Learning Objectives •  Increase understanding of the CARF definition of Interpretative summary. • Increase understanding of the function and purpose of the interpretive summary • Improve knowledge of the how to create person centered individual plans by using the person’s strengths, needs, preferences embedded in the objectives.

3. Why this training? • On 5/4/04 a CARF trainer noted that although Community Mental Health Centers have shown an improvement in this item, as of 2003, 20% of CMHC’s surveyed were still cited for their poor Interpretive Summaries. • This on-line training, of 21 slides, which may be printed (in black/white option with 2-4 slides per page), has been developed to help clinicians improve their Interpretive Summaries.

4. Definition Interpretive Summary: a paragraph or paragraphs written to integrate and interpret history and assessment collected. Also addresses co-occurring disabilities in terms of how they will be considered in developing the individual plan. • The Interpretive Summary should summarize the relevant information and stand alone as if there was no other information, forms or notes.

5. Contents of Interpretive Summary: What to Use from Initial Clinical History and Evaluation • Central theme(s) apparent in the presentation of the person served. • Histories (family, cultural, marital, work) and assessments (medical, psychosocial, spiritual, vocational, etc.), with special emphasis on potential inter-relationships between sets of findings. • Mental Status

6. Contents of Interpretive Summary: cont’d • The perception of the person served of his/her needs, strengths, stage of change, limitations, and problems. • Clinical judgments regarding both positive and negative factors likely to affect the person’s course of treatment and clinical outcomes after discharge (i.e. recovery). • GAF/Level of Functioning

7. Contents of Interpretive Summary: cont’d • Recommended treatments, including any further/special assessments, tests, etc., as well as routine procedures (e.g. laboratory tests). • A general discussion of the anticipated level of care, length and intensity of treatment, and expected focus (goals), with recommendations.

8. Points to Remember • Supports the Diagnostic Impression • Leads to the Individual Plan • Suggests Discharge Planning criteria • A stand-alone document

9. Example: How to Write the Interpretive Summary from the point of participant Admission 1. Intake Information: Twenty-seven year old Michael c/o becoming an excessive worrier a year ago. He is a computer repairman and spends the majority of his day worrying about his work which lowers his productivity. Today, Michael showed no signs of being anxious or depressed. Michael has no AOD/medical problems and his last physical was a year ago.

10. Example: How to Write the Interpretive Summary from the point of participant Admission 1. Intake Information-cont’d: Family history indicates a great deal of marital conflict in both his parents’ as well as in his own 3 yr. marriage. Michael claims his parents’ marriage was maintained for the “sake of the children” and that he has bothersome memories from his childhood. Michael reports experiencing a high level of distraction, irritation, restlessness, and being on edge which sometimes leaves him fatigued and mildly depressed.

11. Example: How to Write the Interpretative Summary from the point of participant Admission 2. Questions to answer when writing Interpretive Summary: • What is the course of the disorder? • What stressors affect the disorder? How? What are the complications? • What may interfere with services? • How is daily functioning affected?

12. Example: How to Write the Interpretative Summary from the point of participant Admission 3. Draft Interpretive Summary Michael (27) has become an excessive worrier over the past 6 months and the majority of his day is spent worrying which causes tension, high level of distraction, irritation, and restlessness. Being on edge sometimes leaves him fatigued and mildly depressed. Michael’s worrying is probably coming from unresolved issues regarding his marital problems, his mother’s death and legal issues resulting from overspending on friends in his desire to be accepted and have friends. Perhaps Michael is also processing normal daily happenings in negative ways. He desires treatment and appears to be in the Preparation stage of change.

13. Example: How to Write the Interpretative Summary from the point of participant Admission 3. Draft Interpretive Summary- cont’d. Diagnosis I - 300.00 Anxiety Disorder NOS II - none III - none IV - Problems with primary support group, occupational problem, legal problem V - 60

14. Items to Carry Over to ITP Example • Strengths: desires Indiv. & Marital Tx, has a steady job • Needs: increase self-esteem, improve independence, resolve bereavement issues • Abilities: intelligent, computer skills • Preferences: pm. appointment

15. Items to Carry Over to ITP Example –cont’d • Goals: “I want to feel better”, “I wanna stop worrying”, “I feel like a failure”, decrease anxiety/worrying, increase self-esteem/confidence, improve decision-making skills, practice positive thinking, grieve mother’s death, develop healthy social support network • Services: Indiv. Tx, Marital Tx, Group Tx, PMA to rule out medication • Outcome/Discharge Criteria: able to relax & manage stress, improved marital communication, improved self-esteem

16. References Migas, N. (2004, May). CARF 2004 Behavioral Health Standards Update. Presented at the South Carolina Department of Mental Health, Columbia, SC. The Commission on the Accreditation of Rehabilitation Facilities (CARF). (2003). CARF Behavioral Health Manual, 2003. Tucson, AZ: CARF

17. Interpretive Summary Training Test • Training Source Document: Interpretive Summary Training Power Point Presentation • Answering 4 out of 5 questions correctly is required to pass.

18. Name _____________________ Date_________Pre Test____PostTest_____Test After Training___ Number Correct___ Answer 4 out of 5 questions correctly is required to pass. 1. An Interpretive Summary repeats the entire assessment including all facts about the participant. ___True ___False

19. 2. Content of Interpretive Summary includes which letter? A. Central theme(s apparent in the presentation of the person served. B. Histories and assessments with special emphasis on potential inter-relationships between sets of findings. C. Mental Status D. Perception of the person served of his/her needs, strengths, stage of change, limitations, and problems. E. Clinical judgment regarding both positive and negative factors likely to affect the person’s course in treatment and clinical outcomes after discharge. F. All of the above.

20. 3. What item listed below is not included in the of Interpretive Summary? A. GAF/level of functioning B. Recommended treatments C. A general discussion of the anticipated level of care, length and intensity of services and expected focus and recommendations. D. Repeats the diagnostic impression.

21. 4. What are the points to remember about the Interpretive Summary? A. Interpretive Summary supports the Diagnostic Impression. B. Interpretive Summary leads to the individual plan. C. Interpretive Summary suggests discharge planning criteria. D. Interpretive Summary is a stand alone document. E. All of above

22. 5. What question(s) should be answered when writing Interpretive Summary: • What is the course of the disorder? • What stressors affect the disorder? How? • What are the complications? • What may interfere with services? • How is daily functioning affected? • None of the above • All of the above