Transcript TREATMENT PLAN Documentation Training

Clinical Documentation
2006 Annual Texas Institute on
Substance Abuse and Mental Health
Rhonda G. Patrick, LCSW
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Clinical Documentation
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ASSESSMENT
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What is the assessment?
An ASSESSMENT is the gathering of relevant
information about the client, their environment,
their problem(s), and what they hope to
accomplish through the therapeutic
intervention.
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Goals of the Assessment
The assessment should answer the following
questions:
► Is
treatment of any kind required?
► 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?
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Goals of the Assessment
The Assessment should answer these basic
Questions:
► Why
is the client seeking treatment?
► How have these problems affected the client’s life?
► What is maintaining these problems?
► What does the client hope to gain from treatment?
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Who can conduct an Assessment?
 Licensed Counselor (LCDC, LPC, LMSW, Ph.D)
 Registered Counselor Intern
Both are:
 Knowledgeable to assess the specific needs of the
client being served
 Are trained in the use of applicable and
appropriate tools
 Are culturally sensitive to the client’s needs
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Parts of the Assessment
► Presenting
Problem or Chief Complaint
► Alcohol and Other Drug Use History (use)
► Family and Social/Leisure History (activities)
► Educational/Employment History (training)
► Legal History
► Mental Health History (mental/emotional
functioning)
► Medical History (HIV, STD, TB, HEP)
► Client Strengths and Limitations
► Recommendations
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Presenting Problem
 Asks the client:
What brings you here today?
Why do you think you need
treatment?
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Alcohol and Drug Use
Substances used in the past
► Substances used recently
► Frequency/amount/duration
► Route of administration
► Year or Age of first use
► Behavior related to obtaining substances
► Use or recovering from alcohol or other drugs
► Previous overdose, withdrawal, or adverse drug or
alcohol reactions
► Attempts to decrease/stop use
► History of previous substance abuse treatment
received
►
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Family, Social & Leisure
 The family history should include:
The occupation and education of patents
The number of siblings and their birth order
The quality of clients relationship to parents
and or siblings
Significant extended family members
Parental approach to child rearing
Familial expectations for the client
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Educational
Educational history can give:
Rough estimate of the client’s level of intelligence
Aspirations, goals, ability to gain from learning
experiences
Willingness to make a commitment
Amount of perseverance
Ability to delay gratification
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Employment
 Employment history can:
be useful in developing an effective treatment plan
give insight into the client’s ability to get along with
others and take direction
show client’s ability for assuming the role of a client
show compliance with treatment recommendations
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Legal History
 Currently legal problems
 probation
 parole
 awaiting
trial/sentencing
 recently released from jail/prison
 Complications with legal situation
 positive
UA
 Are legal problems directly related to
substance use?
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Mental Health History
 Can shed light on whether the current problem
is part of a single or recurrent episode.
 A progression of behavioral health problems
over a period of time.
 What treatment approaches have or have not
worked.
 Client’s willingness to engage in the treatment
process.
 Get an idea of current emotional functioning.
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Medical History
 At a minimum document:
any significant illnesses
hospitalizations
past and current physical illnesses or conditions
breast or prostate cancer
diabetes
hypertension
injuries or disorders affecting the central nervous
system
any functional limitations
HIV, STD, TB or Hepatitis exposure or contact
cursory family history of significant medical
problems
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Recommendations
 The assessment must include:

The clinical recommendations
 counseling
 education
 treatment

Recommendation for treatment must indicate the level of care
 Detox
 Residential
 Outpatient
►
What are the recommended:
 services
 length of stay
 intensity of services
►
Diagnostic Justification Summary
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DSM-IV Multi-axial Diagnostic System
► Axis
I
► Axis
II
► Axis
III
► Axis
IV
► Axis
V
(Clinical Disorders, other conditions that may be a focus of
attention) Examples: Substance abuse, substance dependence,
anxiety disorders, mood disorders, schizophrenia
(Personality disorders, mental retardation) Examples:
Borderline personality disorder, antisocial personality disorder, avoidant
personality disorder, mental retardation
(General medical conditions) Examples: Cancer,
Hypertension, Diabetes, Migraines, Chronic Pain, Injuries
(Psychosocial and environmental problems) Examples:
Problems with primary support group, occupational problems,
problems relating to social environment
(Global assessment of functioning) Example: GAF Score
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Other Issues
► Problem
Complexity
► Readiness to Change
► Resistance to Change
► Social Supports
► Coping Styles
► Motivation
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Treatment Planning
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The purpose of Treatment Planning
► To
clarify the treatment focus
► The set realistic expectations
► To establish a standard for measuring treatment
progress
► The facilitate communication among professions
(both Clinical and Support)
► To support treatment authorizations
► To document quality assurance efforts
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Treatment Plan Content
► Problem
List
► Presenting Problem
► Goals
► Objectives
► Treatment
► Interventions
► Criteria for Discharge
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Treatment Problem Format
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Problem List
►
Problems that are judged by any of the potential referring
parties to:
 have a significant impact on the client’s ability to function
appropriately and adequately in any sphere of life (e.g., family,
social, work, school)
 be amenable to behavioral health care intervention should be
listed here
►
The identified problems should be stated in clear and
unambiguous language in the treatment plan
 Example:
► “problems
in school” could mean a lot of things for a given client,
instead “academic underachievement,” “disruptive behavior
during class,” for “aggressive behavior outside the classroom”
provides a better description of the problem that would be the
focus of the treatment.
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Presenting Problem
►
►
►
►
►
Should contain a statement about the problem for
which the client is seeking treatment.
Clarification of how the problem is evidenced for this
specific client.
Identification of the symptoms that fit DSM-IV criteria
Should always be documented in the client’s own
words.
The client’s own problem description frequently can:
 convey more information about themselves
 the intensity of the problem
 and how these problems affect their life then
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Treatment Goals
► The
counselor and client will identify of
treatment goals.
► Goals can be client-identified or thirdparty goals.
► It is important to have clients identify
what the anticipated or hoped-for results
of achieving their goals will be.
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Client-Identified Goals

Ask the client directly what their goals are
using these three questions:
What do you see as our biggest problem?
2. What do you want to be different about your
life at the end of your treatment?
3. Does this goal involve changing things about
yourself?
1.
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Client-Identified Goals, Cont.
 Does this goal involve changing things
about yourself?
This question forces the client 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 clients to gain insight into their problems – a
therapeutic goal in and of itself.
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Client-Identified Goals, Cont.

Ask clients the following questions relating to
establishing objective outcome criteria for
goal achievement:
How will you know when things are different?
2. What kinds of things will you be doing differently?
3. What negative things will no longer be present?
4. What positive things will you be doing?
These questions offer clients an opportunity to gain
insight into their problems.
Clinician feedback can help clients see how realistic their
expectations are for treatment and determine whether
those expectations should be modified.
1.


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Third Party Goals
 Treatment goals set by non-client
stakeholders in the treatment process must
always be considered, examples:
 spouses
 judicial
system
 employer
 family members

Third party expectations of outcomes should be
sought and/or modified based on the clinician’s
evaluation of how realistic they are.
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Treatment Plan Objectives
►
The following questions can be used
to determine if they are realistic:
1.
2.

Does the client have the motivation to
do the work that is required?
Does the client have a support system
to assist them?
The reality of the situation must be taken into
consideration when determining whether a specific
goal, objective, or time frame should become part of
the treatment plan.
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Treatment Plan Objectives
►
Goals and objectives should be:
 stated in measurable terms
 goals and objectives should be quantifiable,
 specific and easily understood by the client and all
stakeholders
►
Measurability allows for:
 tracking client progress through the treatment process
 providing information regarding the effectiveness of the
treatment plan
 allows the client to see what they have accomplished
through the treatment process
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Treatment Plan Objectives
► Goals
should be stated in the positive (e.g.,
Increase the client’s level of self-esteem).
► Statements in the positive reinforce the idea
that the client is striving to gain something
rather than lose something.
► It is often difficult to attain a positive goal
without eliminating or reducing one or more
types of behaviors, emotions, or cognitions, it
is appropriate to state objectives in the
negative.
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Treatment Plan Objectives
► The
► The
goals and objectives should be prioritized.
goals and objectives priority should mirror the
priority assigned to the problems.
► The client can work toward achieving one or more
goals at a time.
► Objectives tied to two or more goals can also be
address simultaneously and represents the most
efficient use of the client’s and the therapist’s
time.
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Treatment Plan Objectives

QUESTIONS TO ASK
 What do you see as your biggest problem?
 Do you think there is an immediate crisis that needs to be
addressed?
 What do you see as your biggest goal in treatment?
 How will you know if you have achieved your goal?
 Does the goal involve changing things about yourself?
 Does the goal involve changing things about other people?
 What problems do you anticipate in reaching that goal?
 How will you be different after reaching the goal? What positive
things will you be doing? What negative things will no longer
be present?
 What skills will help you achieve the goal?
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Interventions
►
►
►
►
The plan for how the therapist will assist the client in
resolving their problems and consequently achieving their
goals and objectives.
For clinicians who strictly adhere to a single therapeutic
approach (e.g., cognitive-behavioral therapy), the
interventions will generally be the same for all clients,
regardless of what the problems are.
The selection of the intervention to be used becomes more
of a challenge for those therapists who are more eclectic in
their treatment orientations.
Interventions are generally direct interaction with the
clinician or other treatment team member and include
individual and group interventions.
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Interventions
►
►
►
►
Treatment plans must include the frequency and duration
of the intervention.
In some instances, statements regarding the frequency
and duration may be nothing more than guesses based on
the therapist’s experience with similar clients, problems
and treatment goals.
Open ended treatment durations should be avoided except
in cases for which long-term or continuous treatment is
appropriate (e.g., schizophrenics or the chronically
mentally ill).
The therapist should try to provide a very specific and
accurate determination of frequency and duration.
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Interventions
 QUESTIONS TO ASK
 Will the planned intervention enable to client to meet all
or most of the documented goals and objectives?
 Does the treating therapist have the skills necessary for
implementing the planned treatment intervention?
 Is what the client will be expected to do realistic?
 Is what the therapist will be expected to do realistic?
 Will the clinician be able to know within a reasonable
amount of time if the intervention is working?
 Could a different type of intervention yield the same
outcome? If so, why was it not selected?
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Criteria for Discharge
No treatment plan would be complete without an
indication of the criteria for successful discharge from
treatment.
► Must include the Texas Department of Insurance
Criteria for discharge from that level of care.
► The therapist and client must have an agreed upon
point at which treatment or a portion of treatment is
considered complete and the services being offered to
the client are terminated or transferred to a more
appropriate LOC.
► The criteria should be objective and measurable and
should reflect the stated goals and objectives.
►
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Treatment Plan Review
► There
should always be a time indicated for
treatment plan review.
► For residential clients, the treatment plan should
be reviewed and updated every 14 days, sooner
if there is a significant change in the client’s
condition.
► For outpatient clients, the review should occur
every 30 days or sooner if there is a significant
change in the client’s condition.
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Progress Note
Documentation
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Progress Note Documentation
►
There should be a progress note documented following:
 each clinical session
 for each day that the client is present in a residential or detox program
 at the time of discharge
Progress notes must be signed by the author, and have
their credentials clearly documented.
► Progress notes must contain the date of the session and
the length of time of the session, with either a beginning
and ending time or a total time spent with the client.
► Progress notes can be written in several different formats.
The following are recommended:
►
SOAP
 DAP
 Gillman HIPAA Progress Note

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S.O.A.P. Notes
► S = Subjective [client’s view of problems or
progress noted, use client’s own words.]
► O = Objective [Therapist’s objective observations
of the clients progress.]
► A = Assessment [Therapist’s assessment of the
client’s affect, mental status, and psychosocial
functioning.]
► P = Plan [Plan for future treatment as it relates to
progress noted.]
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D.A.P. Notes
►D
= Data [Therapist’s observations, what
the clinician saw and heard, quote
statements made by the client.]
► A = Assessment [The therapists
assessment of the client’s mental status and
psychological functioning.]
► P = Plan [Plan for future treatment as it
relates to progress noted and updating of
the treatment plan.]
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Gillman HIPAA Progress Note
► This
is a new system used to document behavioral
therapy notes
► Created by Peter B. Gillman, PhD,
► Response to the HIPAA regulations around
psychotherapy notes.
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Gillman HIPAA Progress Note
►
The Gillman HIPAA Progress Note contains the
following elements:











Counseling session start and stop time
Modalities of treatment furnished
Frequency of modalities furnished
Medication prescription and monitoring
Results of any clinical tests or assessments
Summary of Symptoms
Summary of Functional Status
Summary of Progress
Summary of Diagnosis
Summary of Treatment Plan
Summary of Progress
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What makes the Gillman HIPAA Note
superior to the SOAP or DAP?
► It
requires the clinician to think in more behavioral
terms.
► It requires the clinician to focus on presenting
symptoms.
► It requires the clinician to think about functional
environments that the client finds more
meaningful to express their psychopathology.
► It requires the clinician to think about the progress
made since the last session.
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What makes the Gillman HIPAA Note
superior to the SOAP or DAP?, Cont.
► It
requires the clinician to think about how the
above data might change their diagnostic thinking.
► It
requires the clinician to think about changes to
their treatment plan and recommendations.
► It
requires the clinician to think about the
prognosis until the next treatment session.
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General Considerations
► Think
about what you will write before you
write it.
► Sign and Date every note.
► Check your notes for grammatical and
spelling errors.
► Limit the use of abbreviations - check with
site as to which abbreviations are
acceptable.
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General Considerations
► Errors
on hand written notes should have a
single line through them, write 'error', initial,
and date.
► Write legibly.
► Avoid blank spaces between entries.
► Include client name and case number on
each page.
► Use direct quotations when reporting
clinically relevant client quotations.
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General Considerations
► Describe
what was observed not just your
opinion about what was observed.
► Tie notes into your treatment plan goals and
objectives.
► Be as brief as is necessary - that is put
enough information down to complete a
note well, but don't put more information
than is necessary.
► Clearly note any risk assessment data and
contracting.
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General Considerations
► Remember
the chart is a legal document.
► Because it is a legal document, you should
start your note right after the last note in
the chart so it will be chronological.
► For neatness sake you may want to start at
the top of a page, so strike out any blank
space above your note.
► You should also provide room for your
supervisor to amend your note at the end.
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General Considerations
► Do
not leave blank lines in between text.
► If you make a mistake, simply cross out the
word with a single horizontal line, write
“error”, and initial it.
► Do not scribble/white out a mistake.
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