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Chesapeake CSB Quality Assurance Training. Learning to Document for Compliance and Quality Of Services. Table of Contents . Introduction – Why document? The Basics Assessment Emergency Medical Service Plan Progress Notes High Risk Discharge .

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Chesapeake CSB Quality Assurance Training

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chesapeake csb quality assurance training

Chesapeake CSBQuality Assurance Training

Learning to Document for

Compliance and Quality

Of Services

table of contents
Table of Contents
  • Introduction – Why document?
  • The Basics
  • Assessment
  • Emergency Medical
  • Service Plan
  • Progress Notes
  • High Risk
  • Discharge

“If writing must be a precise form of communication, it should be treated like a precision instrument.It should be sharpened, and it should not be used carelessly.”Theodore M. Bernstein

good documentation gives direction
Good Documentation gives direction
  • Proper documentation provides you and the individual receiving services with a map of best possible routes and quickest strategies to get to goals. Without this map, our sessions can easily become aimless wanderings.
how does good documentation save time
How does good documentation save time?
  • Eliminates uncertainty about content
  • Assists in linking the tx plan to the note
  • Facilitates quarterly reviews
  • Provides information more rapidly
summary why is documentation important to you and the individual receiving services
SummaryWhy is documentation important to you and the individual receiving services?

Protects the service recipients, staff, and agency :

a) Provides critical emergency information

b) Allows other team providers to help

c) Maintains licensure

d) Supports payment for services as it is written - proof of the great work you have done

e) Enhances quality of treatment

the basics
The Basics
  • Credentials after signature, QIDP, LPC, QMHP, LSCW
  • Clear, precise, easily understood language
cardinal rules for documenting
Cardinal Rules for Documenting
  • When later signing a document, always use the current date for the date signed.
cardinal rules cont
Cardinal Rules (cont.)
  • *Late entries/errors:

a) should be minimal

b) indicate that the information

documented regarding past dated services

or to correct an error is documented and

signed with the current date so as not to

appear fraudulent, e.g.

Example: “As I review my notes I see I forgot to document….”

*Note: Also refer to Credible Manual on “M” drive

for EMR error correction/addendum SOP.

cardinal rules continued
Cardinal Rules (continued)

c) include why the entry is late

d) any note > 30 days past the service is TOO late

e) NO late entry in response to threatened


f) never make a late entry when document has already been copied and given out

general documentation principles
General Documentation Principles
  • Format – Complete forms fully.
  • No response can be interpreted that the

issue or question was not addressed.

  • It is better to indicate N/A, than To leave it blank.
the golden thread
The Golden Thread


Individualized Service Plan

Progress Notes

Discharge Summary

desired outcome flows from beginning to end


Assessment Elements

  • Does your evaluation include when applicable:
  • Individual’s statement of need/preference
  • Medical/clinical necessity
  • Precipitant, hx of presenting need, duration of symptoms, family/social history
  • Current and historical medical, SA, psychiatric info
  • Mental status with risk assessment detail as needed
  • STRENGTHS and limitations
  • Dx that fits presenting problem/need, mental status, client history
  • Recommendations match diagnosis/desire/need
assessment time frames
Assessment Time frames
  • MH/SA intake: 15 calendar days from admission
  • MH Case Management: 30 days from service initiation
  • MH Psychosocial Licensed Authorization Assessment/MH Support Services: within 30 days of service initiation
  • ID/MR Waiver: 60 days from service initiation
  • ID/MR Case Mgt.: 90 days from admission w/o ID/MR
  • diagnosis

Emergency Medical Info

Have you specified:

Allergies to medication?

Emergency Medical Contacts?

PCP information: Who, how to contact, OK or refuse to have contacted? (Do not forget Client Authorization if OK)

Checked all Health Habits or marked “None”?

Updated as arises and/or annually on EMR Medical Profile?

preliminary isp
Preliminary ISP
  • Brief - to cover the 1st 30 days prior to development of ongoing ISP which is then due
  • To be completed within 24 hours of


  • Provides initial agreed upon plan to

engage individual in requested services

  • State licensure requirement
isp do s don ts
ISP Do’s & Don’ts
  • Complete ongoing ISP within 30 days of admission
  • Include date of assessment from which goals are derived
  • for reference to the assessment
  • Clearly define problem or need/desire: no vague, global
  • statements that could apply to any individual
  • Develop behavioral, measurable, attainable goals/objectives
  • that are individualized to the client
  • Tailor target date to fit specific goal/objective; different
  • goals or objectives often have different time frames.
  • Include staff interventions and frequency to facilitate
  • individual reaching their goal.
isp do s don ts cont d
ISP Do’s & Don’tscont’d
  • Include minimum criteria necessary to be ready for
  • discharge on ISP discharge plan
  • If other agencies are involved, list them.
  • Don’t forget responsible staff’s signature, date and the
  • service recipient’s signature.
  • If a legal guardian or legally authorized rep, or significant
  • family members involved, include them in planning and
  • signatures
isp do s don ts cont d1
ISP Do’s & Don’tscont’d
  • Don’t forget to update ISP when changes occur
  • List items of concern even if the individual does not
  • want to work on them and what interventions of encouragement are to address these concerns, e.g.:
    • Don’t forget medical issues, when they arise, including
    • steps to encourage and support the individual’s follow up.
  • 2) Don’t forget to include substance abuse, if applicable,
  • including steps to encourage and support follow up
isp don ts
ISP Don’ts
  • Do notinclude that you will be working with the consumer’s parent for guardianship when the parent has been deceased or any other intervention with the family member who is deceased! This has occurred and demonstrates that the clinician has not read the ISP nor reviewed the content of the ISP with the individual or AR when obtaining the signature.
isp do
  • Do watch any copying of previous
  • documentation on to current documentation
  • to assure that past information no longer
  • relevant is not included and that note is individualized and current.
  • Do treat the ISP as a blueprint or living document to guide the individual’s services by reviewing it on an ongoing basis with the individual receiving services.
isp quality check
ISP Quality Check
  • Is the ISP one that you would desire for yourself or your family member?
  • Ethics of Documentation – Is the ISP individualized to fit the unique individual served?
quarterly review
Quarterly Review
  • Review individual’s progress or lack of progress per ISP goals
  • AND
  • review individual’s satisfaction with their services each quarter.
  • Any barriers to progress?
  • Any modifications or updates needed?
  • Document all of the above within 90 days of ISP date and
  • every 90 days thereafter
progress notes
Progress Notes
  • Written and approved within 48 hours of service except for Outpatient which must be within the date of service per Medicaid regulations.
  • Dated and signed by provider w/credentials, e.g. QIDP, LCSW, QMHP
  • Type and date of contact: face to face, phone
  • Time frame contact covers, e.g. 60 minutes, week of, month of
  • Modality or service: case mgt., crisis intervention, group therapy, residential support
progress notes cont
Progress notes (cont.)
  • Document:
  • A) who is present
  • B) current functioning, include strengths

C) ISP goals addressed during contact

  • D) progress or lack thereof
  • E) interventions/strategies employed
  • F) plan, including homework and next appt.
clinical observations
Clinical Observations
  • Are only relevant if they are discussing issues related to presenting problems, pre-existing or new
    • For example: If hygiene has never been an issue then it should not be discussed in the note.
  • Are important in supporting baseline behavior demonstrating current level of functioning
    • For example: If an individual is always delusional about his family, mention that the individual continues to demonstrate delusional behavior or that no changes in baseline have occurred.

Progress notes (cont.)

Avoid subjective, critical statements:

Service recipients have the right to inspect their records and request amendments (human rights regulations, HIPAA regulations,

VA Privacy Act)

Be concise; stick to the facts.

the more specific the better
The more specific the better
  • When describing symptoms support your words with FACTS.
    • For example: “(Individual’s name) looked depressed as evidenced by (AEB) slumped posture, tearfulness, and poor eye contact.”
  • Avoid words that sound like judgments
    • “(Individual’s name) looked sloppy” replace with “(Individual’s name’s) appearance was disheveled (AEB) stains on his shirt, pants with holes in them, shirt buttoned incorrectly.”
topics discussed
Topics discussed
  • “Discussed individual’s difficulty in following through with completing her job applications.”
  • “Home visit focused on the importance

of completing ADL skills to maintain

current living situation.”

  • “Session focused on the four times

individual has been in the hospital for

suicidal gestures.”

  • “(Individual’s name) stated, “I want to

work on my issues about rejection.”

  • “(Individual’s name) stated, ‘I identified 4 positive traits that I have!’”
strengths and weaknesses
Strengths and Weaknesses
  • Our service recipient’s abilities and limitations change throughout the course of therapy and/or other services.
  • Because we try to base our treatment plan on what those strengths and weaknesses are at the beginning of treatment, it is necessary to document how these changes will affect the course of treatment and the plan of care. Don’t forget to emphasize the positive.
proper wording
Proper wording...
  • “(Individual’s Name) continues to use sober supports such as AA meetings and sponsor when she feels the urge to drink.”
  • “(Individual’s Name) no longer has family support available to him, as his family has moved 50 miles away. A new goal will focus on learning to use available community supports.”
  • “Although “(Individual’s Name) interest in artwork and drawing was originally seen as a positive interest, it is now seen as a stressor as he has unrealistic expectations of his ability to become famous and becomes frustrated and depressed when drawing.”
medical necessity
Medical Necessity
  • Reimbursement for services depends on whether services are NECESSARY
  • This means the service we provide must be consistent with the individual’s documented needs
  • If an individual is not making progress, payers want to know why.
  • Documenting setbacks and or additional stressors is important!
  • It also helps us to know when revisions are necessary to the treatment plan
examples of documenting setbacks
Examples of documenting setbacks
  • ““(Individual’s Name) reports that the recent death of her mother and concerns about possible eviction from her home are making it impossible for her to focus on homework assignments and she has missed 3 days of hospitality in the past 2 weeks.”
  • “Continued need for case management services AEB client’s inability to obtain community supports, manage medical visits and pursue proper entitlements by himself.”
documenting progress
Documenting progress
  • If an individual is making progress, its important to document this.
  • This information reinforces not only the necessity of service but the efficacy of the treatment we provide.
  • Don’t forget to celebrate with the individual served!
examples of documenting progress
Examples of documenting progress
  • “Progress is evidenced by “(Individual’s Name) initiating discussions in session, displaying a bright affect, and no longer crying during session when discussing losing his job.”
  • “(Individual’s Name) behavior has improved AEB verbal report from mother, no incidents of fighting at school in the last 2 weeks, and child’s ability to sit through entire session without temper tantrum.”
functional limitations
Functional Limitations
  • Refers to the level of disability resulting from an MH, SA, or ID/MR diagnosis and how this results in limitations or problems in major life activities.
functional limitations cont d
Functional Limitationscont’d
  • Problems in major life activities are defined as:
    • Poor employment history
    • Need for public financial assistance to remain in the community and difficulty obtaining this assistance alone
    • Difficulty establishing or maintaining personal social support network
functional limitations cont d1
Functional Limitationscont’d
  • Need for assistance in ADL’s including food prep. Or budgeting

Exhibits inappropriate behavior that often results in intervention by mental health or judicial system

*In order for a person to meet the criteria for continued CM they must meet two or more of the above.

session and treatment plan
Session and Treatment plan
  • Progress notes function as a means of tying the treatment plan and actual session together. The goal, objective, and intervention #’s link the ISP to treatment and map to the progress note for continuity between the documents.
  • “Worked on Goal 1, Obj 1, by role playing various assertive behaviors.” Additional statements could indicate specific issues or interventions used to address these objectives.
sessions and treatment plans cont
Sessions and Treatment planscont.
  • If a progress note has no relationship to the treatment plan, one of two things should happen:
    • If some new issue has come up or crisis has developed then the treatment plan may need to be revised
    • If the session was unfocused and unsuccessful, plans to implement the treatment plan in the next session should be identified as well as reasons why this session was unproductive.
sessions and treatment plans cont1
Sessions and Treatment planscont.
  • Keeping in mind that all progress notes should relate back to the Plan of Care, can assist in maintaining focus within a session
linking objectives
Linking objectives
  • “While discussing current causes of low self -esteem (Goal 2, Obj a) “(Individual’s Name) identified the role her mother plays in negative thinking patterns.”
  • “While completing food stamp application (Goal 3, Obj a) “(Individual’s Name) discussed difficulty in concentration and sleep problems occurring the last two nights in a row.”
  • No one gets better by magic! Take credit for the hard work you do by documenting the type of interventions you use to help the individual achieve their goals.
  • Remember there’s a section on the treatment plan devoted to the interventions we plan to use. Documenting them reinforces that we ARE doing what we say we’re going to do.
interventions cont
  • “Role playing was used to assist “(Individual’s Name) in preparing for tomorrow’s job interview.” (Goal 3, Obj b)
  • ““(Individual’s Name) was provided a pamphlet on Prozac and its side effects. CM reviewed this information with the client.” (Goal 1, Obj c)
  • ““(Individual’s Name) participated in a group activity which included watching an educational video on relapse prevention. Afterwards he was able to identify 3 personal triggers to his own past relapses.” (Goal 2, Obj a)
interventions cont1
Interventions cont.
  • “CM assisted “(Individual’s Name) in developing a grocery list and accompanied him to the store. CM used verbal cues and modeling to assist “(Individual’s Name) in appropriate behavior while grocery shopping. “(Individual’s Name) was able to complete shopping with no disruptive behaviors in the store.” (Goal 2, Obj d)
progress notes cont1
Progress notes (cont.)
  • Can another staff person who does not work with the individual read the note and understand the individual’s need, how it is being addressed, and how they are responding to the interventions?
progress notes cont2
Progress notes (cont.)
  • Document informing others on

the team matters pertaining to

the individual via note and EMR warning, to do, and/or instant message, e.g. “(Individual’s Name) *revoked authorization to disclose information for family member, or was hospitalized or reports medical problem or admits to abusing substances, and/or what team members would need to know to provide quality services for the individual. Documenting the outcomes of phone calls and meetings also keeps the team informed.

*Refer to Credible EMR Manual, “M” drive, “SOP for Revocation of ROI”

progress notes cont3
Progress notes (cont.)

If the individual is noncompliant to the agreed upon ISP goals/services document their noncompliance and the plan for follow up to address the noncompliance in an encouraging manner.

homework assignments
Homework Assignments
  • It is important to remember that much of the individual’s work happens outside of our office/session/visit.
  • With this in mind, we have to utilize the time the individual spends away from us, to reinforce the information they’re getting in treatment.
  • Being able to generalize what they’ve learned to the ‘outside’ world is a large part of recovery.
homework assignments must link to the treatment plan
Homework assignments must link to the treatment plan
  • “(Individual’s Name) reports initiating three conversations at HC, as rehearsed in previous session. (Goal 1, Obj a)
  • “(Individual’s Name’s) mother reported he completed his chores without argument this week and has kept his room clean and neat. (Goal 2, Obj a & b)
  • “(Individual’s Name) reports attending 3 AA meetings and produced a sign-in sheet from each meeting.” (Goal3, Obj b)
plan or directions for future treatment
Plan or directions for future treatment
  • ““(Individual’s Name) is under significant stress at this time; consequently, the number of sessions will be increased from 2/month to 1x/wk.”
  • “Next session will focus on “(Individual’s Name) budgeting issues.” (Goal 2)
  • “Continue addressing self-esteem issues.” (Goal 3)
appointments referrals and consultations
Appointments, Referrals, and consultations
  • “Referred to Dr. Smith for medical evaluation on 3/15/01 @ 2pm.”
  • “(Individual’s Name) will be referred to Psychological Consultants, Inc. for psych testing. CM unable to get appt time today, will pursue this week.”
  • “(Individual’s Name) will see Dr. Brown, PCP, on 5/25 @ 10am.”
putting it all together
Putting it all together
  • Knowing what needs to go into a progress note is only half the battle
  • We have to know how to group the information in a manner that makes sense
  • Choosing a progress note format that facilitates this process is important
  • Document a narrative note that is presented in a condensed, concise fashion.
  • Provide data that focuses on service recipient’s self-reports, observations made during the session, current issues/stressors, functional impairment and strengths.
  • Include information that focuses on the effectiveness of the current session, progress, motivation, effectiveness of treatment strategies, completion of treatment plan objectives, and the need for diagnostic revisions.
  • Don’t forget a Plan that focuses on your strategy for relieving the individual’s problem, including immediate or short-term actions and long-term measures, which may include your interventions, evaluations, and any revisions you might need to make to the plan. This would also be the section where homework assignments and referrals are cited.
high risk documentation
High Risk Documentation
  • For all service recipients, be sure to include any self-destructive or aggressive behavior, e.g. suicidal, homicidal, eating disorders, self-mutilation, head banging, severe scratching, biting, slapping themselves or others in your assessment.
high risk documentation1
High Risk Documentation
  • Note current or past suicide/homicide

ideation, plan and/or intent.

  • Include any family history of suicide.
  • History of overdose? If so, what type of meds, amount taken, age of individual at time of overdose, did individual alert anyone? Who presently administers meds?
high risk doc cont
High Risk Doc. (cont.)
  • If threat of service recipient currently overdosing or stockpiling meds, document alerting MD, family members, residential staff, clubhouse, vocational staff, etc. Use EMR Warning as well as note.
high risk doc cont1
High Risk Doc. (cont.)
  • Document your assessment of current risk and decision making process re: what steps to take or if none, why?
high risk doc cont2
High Risk Doc. (cont.)
  • Some steps to immediately take

and document:

  • individual has been educated re: agency emergency after-hour protocol
  • Use crisis mgt. plan service type in EMR to document crisis plan with individual to include safety strategies and provide copy for individual with after hour contact information. (Include as ongoing ISP goal.)
high risk doc cont3
High Risk Doc. (cont.)
  • Document consultation w/supervisor.
  • Schedule psychiatric evaluation w/approval of supervisor and note in record.
high risk doc cont4
High Risk Doc. (cont.)
  • Document a risk plan, e.g. secure services of a behavioral consultant and how team staff was trained to implement safety plan for individual to address self-injurious or aggressive behavior toward others. Include on ISP.
high risk doc cont5
High Risk Doc. (cont.)
  • When documenting the assessment of risky or self-destructive behavior, also include any events or situations that may trigger the risk or generally arises before the behavior.
high risk doc cont6
High Risk Doc. (cont.)
  • Some examples:

relationship conflict (very common)

workplace problems

substance abuse

financial problems

health problems

high risk doc cont7
High Risk Doc. (cont.)

Document at end of assessment and on

ISP recommended interventions and referrals to address these situations to decrease the likelihood of such behavior. This is to include focus upon the individual’s strengths.

high risk doc cont8
High Risk Doc. (cont.)

Examples of such referrals/interventions:

  • stress, anger, and/or communication skills training
  • education about depression
  • referral to AA or other support groups
  • positive skills to help individual tolerate distress
  • to continue to monitor individual
high risk doc cont9
High Risk Doc. (cont.)
  • Document ongoing monitoring of assessed high risk behavior. Note at each contact an assessment of risk symptoms/behavior, interventions applied, and plan for follow up as needed.
discharge summary
Discharge Summary
  • Should be consistent with the ISP

discharge plan and criteria.

  • Include:

a) reason for discharge

b) progress made

c) individual’s/family’s participation in discharge


d) individual’s level of functioning at discharge

discharge summary cont
Discharge Summary (cont.)

e) discharge medications, if applicable

f) discharge diagnosis, if applicable

g) discharge referrals/recommendations

h) individual’s date of discharge and date

summary is written

i) signature of responsible staff

discharge summary cont1
Discharge Summary (cont.)
  • If individual has been receiving CCSB med services, include MD agreement for agency discharge. (refer to Protocol for Discharge w/physician approval – Credible EMR Manual on “M” drive)
  • Discharge data should be completed in a timely manner within 30 days of actual discharge.