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Mental Health and Substance Abuse Records

Mental Health and Substance Abuse Records . HIM 2000. Mental Health Care Settings. Outpatient Mental Health Facility Group Home Personal Care Home Psychiatric Care Facility Inpatient Psychiatric Hospital. Mental Health.

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Mental Health and Substance Abuse Records

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  1. Mental Health and Substance Abuse Records HIM 2000

  2. Mental Health Care Settings • Outpatient Mental Health Facility • Group Home • Personal Care Home • Psychiatric Care Facility • Inpatient Psychiatric Hospital

  3. Mental Health Most prevalent types of mental illness are schizophrenia, bipolar disorder (manic depression), and clinical depression. Serious mental illness results from a chemical imbalance in the brain.

  4. DSM IV-text Revision DSM-IV-TR (2000)developed by the American Psychiatric Association. The DSM-IV-TR is a classification system and nomenclature of mental disorders. It offers clinicians the option of assessing clients and recording their findings in a multiaxial format (pg 260 & 270 in text).

  5. Types of Surveys • State licensing agency • JCAHO, Comprehensive Accreditation Manual for Behavioral Health Care • Inpatient and outpatient facilities • Commission on Accreditation of Rehabilitation Facilities (CARF) • Mental health and psychosocial rehabilitation programs

  6. Documentation • Assessment – focuses on patient’s apparent needs and whether the facility can address those needs • Must include educational assessment and plan for adolescent patients • Treatment plan – steps to mitigate or eliminate the problem outlined in assessment • Progress notes • Special Treatment procedures • Discharge Summary and Aftercare plans

  7. Conditions of Participation • Medical history • Physical findings • Laboratory and diagnostic test results • Diagnosis • Treatment record

  8. Mental Health & HIPAA Mental Health Facilities may release private health information for treatment, payment, and operations. Psychotherapy notes are an exception. Psychotherapy notes are like process notes that captures the therapists impressions about the patient. These notes were not intended to communicate or seen by other persons then the therapist.

  9. Substance abuse Involuntary commitment is a legal process by which individuals who are deemed to be a danger to themselves or to others may be admitted to a treatment program even though they refuse or cannot consent to the treatment.

  10. Mental Health & Substance Abuse Confidentiality Because of the stigma that is attached to substance abuse, mental health & substance abuse records must abide by HIPAA and federal law (42 CFR) that state certain procedures must follow before releasing client information in drug and alcohol programs.

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