Transcript Interpretive Summary

How to Write Meaningful
Interpretive Summaries
Updated 7/09 for CDS Staff
A CDCMHC/Quality Improvement Dept. Version 7/04
Interpretive Summary Training 2
Learning Objectives
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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.
07/09
Why this training?
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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.
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Definition
Interpretive Summary: a paragraph or paragraphs
written to integrate and interpret history and
assessment collected.
Also addresses cooccurring 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.
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Contents of Interpretive Summary: What to
Use from Initial Clinical History and
Evaluation
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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
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Contents of Interpretive Summary: cont’d
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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
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Contents of Interpretive Summary:
cont’d
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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.
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Points to Remember
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Supports the Diagnostic Impression
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Leads to the Individual Plan
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Suggests Discharge Planning criteria
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A stand-alone document
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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.
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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.
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Example: How to Write the Interpretative
Summary from the point of participant
Admission
2. Questions to answer when writing Interpretive
Summary:
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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?
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.
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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
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Items to Carry Over to ITP
Example
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Strengths: desires Indiv. & Marital Tx, has a steady job
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Needs: increase self-esteem, improve independence,
resolve bereavement issues
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Abilities: intelligent, computer skills
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Preferences: pm. appointment
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Items to Carry Over to ITP
Example –cont’d
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Goals: “I want to feel better”, “I wanna stop worrying”,
“I feel like a failure”, decrease anxiety/worrying,
increase self-esteem/confidence, improve decisionmaking 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 selfesteem
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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
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Interpretive Summary Training Test
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Training Source Document: Interpretive
Summary Training Power Point
Presentation
Answering 4 out of 5 questions correctly is
required to pass.
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Name _____________________
Date_________
Pre Test____Post Test_____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
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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.
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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.
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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
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5. What question(s) should be answered
when writing Interpretive Summary:
A.
B.
C.
D.
E.
F.
G.
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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