Progress Notes Made Simple

1. MHRS & ParaproDocumentation Practicum County of San Diego 3/13/2018

2. Welcome to improvement • One hour session • Facilities (restrooms, parking, etc.) • Emergency exits • Cell phones

3. Today you will: • Review Service Codes for Case Management and Individual Rehab. • Write an effective progress note(s)

4. Documentation practicum • The Mental Health Plan (MHP) gets paid for providing Specialty Mental Health Services (SMHS) because of the interventions that you provide to your clients. • A good progress notes means that WE GET PAID FOR YOUR VALUABLE WORK. • We don’t get paid for providing non-SMHS, but sometimes we need to provide these services to clients.

5. PROGRESS NOTES MADE SIMPLE • Writing a great progress note can be a simple process • Writing a great progress notes gets better with practice and experience • Writing a great progress note will always include: • A target impairment that needs an intervention • An intervention to make the impairment better • The client’s response to that intervention • The plan for future services based on client plan needs

6. Documentation practicum FOR EXAMPLE: • My client struggles with depression which causes them to isolate, feel hopeless and lonely. Without help, my client may get more depressed and give up. • To help my client, I want to provide a Case Management service to find some places the client could use to decrease isolation and get more social interaction which should help their mood. • I provided resources to a clubhouse and a local peer recovery group. I educated him/her about what support these can provide. • We plan to complete a visit to the clubhouse when we meet next week.

7. Medical Necessity – What is it? • Medical Necessity contains 3 key things: • An included DSM V Diagnosis related to a client’s mental health. • The most common diagnoses that our MHP treats are DEPRESSION, ANXIETY, BI-POLAR DISORDER, BEHAVIORAL DISORDERS, AND SCHIZOPHRENIA OR OTHER THOUGHT DISORDERS. • The symptoms of the diagnosis cause problems for the client in their daily living, like not being able to work, or go to school or public places, not engaging with family, or having relationship problems with family, friends, or children. • The Intervention that you provide to your client is targeted to help improve the impairment life functioning.

8. Rehabilitation Services Purpose: To improve, maintain or restore SKILLS in life functioning. It is Not: Providing only academic, work training, or recreation activities to or with the client Documentation must be connected to and address the Client Plan Objectives

9. Rehab. – Individual SERVICES Service Code 34 - Rehab. Individual: Teaching activities to help a client when they are experiencing anger, hyperactivity, worry, fear or… Helping a client learn hygiene, self care or life or social skills Educating, encouraging and supporting them about the benefits and need for consistent attendance to Mental Health appointments Talking with a client and trying to help them come up with ideas to help solve their problems about concerns, or difficulties

10. Case management Service Code 50 - Case Management: Provide connection with or assistance to getting community resources Identify, discuss and contact resources for client or family Connect a client or support person directly to a resource Monitoring client’s progress towards treatment goals Remember, all of these activities must be related to the Client Plan

11. A Good Progress note: The impairment The intervention The client response to the intervention The plan for next services based on client plan

12. It’s documentation time NOW LET’S PRACTICE!