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TIFFE/CAMHD Documentation Training
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  1. TIFFE/CAMHD Documentation Training

  2. GOALS • To ensure clinicians are adherent to CAMHD/TIFFE documentation requirements (i.e., format, timeline, structure, etc). • To ensure clinicians produce/provide quality of documentation (i.e., individualized to each client/family, S.M.A.R.T.).

  3. AGENDA • Pre-test • Required Intake Forms. • Mental Health Treatment Plan (MHTP). • Progress Notes • Monthly Treatment and Progress Summary. • Sentinel Events Report. • Annual Summary Reports. • Behavioral Plan. • Discharge Summary.

  4. INTAKE FORMS • Handout and Sample.

  5. THE PURPOSES of MHTP • Contract agreement between client and provider. • Guide the course of treatment for identified problems or issues. • Evaluate the client’s progress in meeting specified goals and objectives. • Mean of communication between providers.

  6. STEPS IN DEVELOPING MHTP • Gather information • Review available information (reports, CSP, medical records, court records, school records, etc.). • Interview process (youth, caregivers/guardians, other provider/treatment team members, etc.). • Develop case formulation • Identify clients’ current situations and what they want to accomplish. • Determine the most effective and appropriate ways to help clients achieve their goals. • Identify possible barriers in accomplishing the goals. • Determine an estimated time to accomplish the goals.

  7. REQUIRED COMPONENTS OF MHTP • Client’s DSM-TR IV diagnosis code(s) consistent with the assessment(s). • Goals and measurable objectives. • Target dates. • Appropriate strategies/interventions (Best Practices). • A list of the services to be provided/who will provide the services. • Crisis plan. • Transition/Discharge Plan.

  8. REQUIRED COMPONENTS OF MHTP • Signature of client (when appropriate). • Signature of the client’s parents, guardian, or legal custodian. • Signature of the treatment team members who participated in the development of the plan (at minimum MHCC). • Date of start and end of services.

  9. MHTP • Goal (WHAT)) • The end point of therapeutic work (Desired outcome). • Example of Goals: • Family = Develop positive family interaction. • School = Improve school/academic performance. • Community = Increase involvement in community activity. • Individual = Improve problem solving skills. • Social/Peer = Develop and maintain positive peer interactions. • Legal = Maintain no involvement in law violation.

  10. MHTP • Objective (HOW) • Step(s) in achieving the goal. S pecific M easurable A ttainable R ealistic T ime-limited

  11. MTPS (Objective Examples)

  12. MHTP (STRATEGIES/INTERVENTIONS • Based on best practice. • Need to consider youth’s diagnosis/issues. • Need to consider youth/family’s cultural in identifying appropriate interventions. • Need to consider youth/family’s resources or lack of resources. • Need to consider youth/family readiness for change.

  13. REQUIRED COMPONENTS OF MHTP • Crisis Planning: Address settings events, triggers, preventive as well as reactive intervention. Must focus on early intervention. • Transition/Discharge Plan: • Begin at the initial meeting. • Describe the supports and necessary services for successful and smooth transition. • Identify the criteria for transition or discharged based on MHTP goals and objectives. • Need to include contigency plan. • MHTP needs to be completed within 10 days of intake.

  14. CHARACTERISTICS of GOOD MHTP • Individualized to each client/family. • Directly linked to achieving goals in a client’s IEP or/and CSP. • Identify client/family’s challenges as well as strengths areas. • Based on strengths, and needs driven. • Must be developed with youth (when appropriate) and parent/guardian involvement. • Written in client/family language. • Problems/issues are stated using positive language. • Goals/objectives/interventions are appropriate to the client’s diagnosis, age, culture, strengths, abilities, preferences, and needs expressed by the client/family. • Goals/objectives/interventions need to be attainable, realistic, measureable.

  15. MHTP GROUP ACTIVITY “Creating A Treatment Plan”

  16. PROGRESS NOTES • Purpose • Serve as documentation of treatment. • Track therapy progress. • Essential part of therapy process. • Ensure quality assurance. • Format (DAP) • D escription: • A ssessment: This section is where you assess, in descriptive terms, the client’s performance during the session and/or the session itself. • P lan: The final section of your DAP notes is where you outline the course of treatment, after considering the information you gathered during the session. Next session date.

  17. PROGRESS NOTES • Things to consider when writing progress notes: • Who are you writing your progress notes for? • Yourself (clinician) • TIFFE (supervisor/program manager/clinical director) • CAMHD (care coordinator, auditor, QA people) • Who will have access to your progress notes?

  18. PROGRESS NOTES • Who will have access to your progress notes? • Agency (Supervisor, Clinical Director, etc.). • Client/Caregiver • CAMHD (care coordinator, chief branch, CAMHD psychologist, etc) • Court system (probation officer, judge, etc.) • Other agency/provider involves in client’s therapy (i.e., teacher, CPS, individual therapist, psychistrist, etc).

  19. Progress Notes • How much information need to be included? • Need to include adequate information in regard what occur in therapy session related to therapy goals/process. • What are the issues being address? • What are the goals being work on.? • How do the issues or goals are being address (specific strategies/intervention)? • How does youth response to intervention? • What progress does youth make (describe the progress)? • Is there any issues that might hinder the youth’s progress? • How does this issue is being address?

  20. PROGRESS NOTES • What types of information need be included? • Only include information, issues, or problems that have direct impact on youth’s level functioning or directly related to treatment.

  21. PROGRESS NOTES • Who Relies On Your Documentation: • Treatment Team members • Referral Sources • To advocate for the most appropriate and effective care for client. • Employers • Other Payors • To justify need for continued treatment, need for admission, demonstrate appropriateness and cost-effectiveness of care, demonstrate all billable services were provided.

  22. PROGRESS NOTES • Samples of good progress notes. • Handouts. • Practice writing progress notes.

  23. MONTHLY TREATMENT AND PROGRESS SUMMARY

  24. SENTINEL EVENTS REPORTS • Purpose • To establish uniform guidelines for a reporting system that is designed to track and document sentinel events and the follow-up of the events reported by the CAMHD Branches and contracted provider agencies (provider). • Definitions • Sentinel Event: An occurrence involving serious physical or psychological harm to anyone or the risk thereof, as defined under the categories of sentinel event codes and definitions. • Critical Event: Events involving serious injury or death, suicidal attempts, sexual misconduct, allegations of staff abuse or misconduct.

  25. SENTINEL EVENTS REPORTS • Procedure • When a sentinel event occurs the provider: • Notify the youth’s legal guardian, and MHCC within 24 hrs of the occurrence of the sentinel event, either by phone of fax. • Complete CAMHD’s sentinel event report form (signed by TIFFE’s clinical director or supervisor on site). • Sentinel event report (signed by clinical director/supervisor on site) need to be faxed to SES and MHCC within 72 hours of the sentinel event.

  26. SUMMARY ANNUAL ASSESSMENT • Purpose: • Address significant changes, current status and consequent recommendation. • Information to be included: • Measures of youth’s behavior and functioning • CAFAS/PECFAS and ASEBA checklist for parents, teacher and youth’s self report form need to be included. • Structure/format (see handout). • Write a progress notes indicating that you are working on Summary Annual Assessment (for billing purpose).

  27. DISCHARGED SUMMARY • Written discharge summary must be submitted to appropriate CAMHD Branches within ONE week of service termination. • Post CAFAS/PECFAS needs to be completed and turn in with your D/C summary. • CAFAS/PECFAS needs to include pre/post score on individual as well as family functioning. • D/C date is the last session you had with youth/family.

  28. SENTINEL EVENT REPORT • Sentinel events Handouts. • Sample.

  29. Closing • Q & A • Post-test • Evaluation