PLEASE STAND BY…

1. PLEASE STAND BY… The webinar will begin shortly. To ensure quality audio we encourage you to use phone audio option All participants will be muted during today’s call

2. CLINICAL DOCUMENTATION WEBINAR LaDessa Foster, LCPC, MAC, NCC May 7, 2019

3. HOUSEKEEPING Audio quality may be improved if listening on phone All attendees are in listen only mode Type questions your into the question box CEs will be emailed to those that attend entire live training and complete survey. No credit for those who leave early Webinar will be posted to website for viewing later. No CEs will be available if watching recorded version.

4. POLL 1Who is on today’s call?

5. OBJECTIVES Upon completion of this webinar participants will understand the do’s and don’ts of good clinical documentation for: • Individual sessions • Groups • Family sessions • Case management

6. CLIENT FILES Treatment Plan Financial Eligibility Assessments PO Status Update reports Client Demographics Info. on Collateral Contacts Referrals Invoices (MAT, Interpreter, etc.) Progress/Encounter Notes Releases of Information Discharge recommendations Drug Testing Results Informed Consent Follow-up Survey Consents ASAM Updates Rights & Responsibilities Discharge Summary

7. CLIENT FILES Treatment Plan Financial Eligibility Assessments PO Status Update reports Client Demographics Info. on Collateral Contacts Referrals Invoices (MAT, Interpreter, etc.) Progress/Encounter Notes Releases of Information Discharge recommendations Informed Consent Drug Testing Results Follow-up Survey Consents ASAM Updates Rights & Responsibilities Discharge Summary Many are required by all payors, others may vary. Read your contracts!

8. WHY DOCUMENT? Professional ethics Historical record for client Assist co-workers in agency in staying informed of client strengths and needs Risk management Financial accounting – billing requirements Contractually required

9. DOCUMENTATION GUIDELINES Focus on documenting medical necessity Tie to treatment plan

10. DOCUMENTATION GUIDELINES (cont.) Treatment plan exceptions: • BPA Health EAP Provider, no plan is needed, however documentation must include the issue being addressed in current authorization • Idaho SUD Network Provider working with an IDOC funded client with a Pre-Treatment authorization

11. DOCUMENTATION GUIDELINES (cont.) Include assessment and observations of: • Physical and emotional symptoms • Behavior (positive and negative) Assess for risk of harm Reflect individualized, evidence-based care Response to and outcome of interventions

12. DOCUMENTATION GUIDELINES (cont.) Document non-routine calls, missed sessions, consultation and collaboration If you didn’t document it, it didn’t happen!

13. POLL 2

14. STANDARD NOTE ELEMENTS Client name/ID Date of service Time of service Type of service/billing code Clinician signature and credentials If an intern or ISAS, supervisor should review and co-sign note

15. DOCUMENTATION FORMATS D.A.P. (Data – Assessment – Plan) S.O.A.P. (Subjective – Objective – Assessment – Plan) Narrative (conversational format – tell story)

16. INDIVIDUAL SESSION NOTES Do document: • Acuity • Strengths • Challenges/barriers AND intervention/plan to address • Focus of session - tie to the treatment plan Don’t document: • Progress only • A problem without a therapeutic intervention

17. BE MINDFUL OF CONTENT IN NOTE Too Much “Sally is having an affair with her boss Bob Smith and is worried this might lead to problems but doesn’t want the relationship to end.” • Better: “Explored with Sally her feelings and thoughts about her romantic relationship and if it is in her best interest.”

18. EXAMPLES OF POOR INDVIDIUAL NOTES “Mary participated in individual session.” Silly Sally Signed by Joker, Jonny 1/25/19 1:00-2:00 PM “Mary reported in individual session that her ex triggers her.”

19. D.A.P. INDIVIDUAL NOTE – BETTER EXAMPLE Signed by Sally, Silly LPC 1/25/19 9:00-10:00 AM D: During the session Mary stated: “My ex has custody of the kids and stands in the way of letting me see them.” Our session focused on how this triggers her thoughts of relapse. Mary was tearful at times; gazed down and fidgeted with her scarf. A: Client feels strongly that family is important in her recovery process. She is motivated to actively parent her children and is looking to resolve conflicts with her ex. P: Addressed Tx Plan Goal 2, Obj. 3, Intervention. 4. Will Address Tx Plan Goal 3, Obj1, Intervention 2 in next 1:1 - 2/7/2019 @ 9:00.

20. POLL 3Progress notes must include…

21. GROUP NOTES Do document: • Date/time of service • Title of group, EBP used and group description • Medical necessity - group MUST be tied into treatment plan • Documentation must be specific to the client

22. GROUP NOTES (cont.) Do document: • Participation (what did client say and do) • Impact of group on the client (positive or negative) • Challenges presented and interventions to address Don’t document: • Same note for each client

23. EXAMPLES OF POOR GROUP NOTES Signed by Isle, Isabel, ISAS 11/10/2018 12:00-1:00 P “Tom was late to group” Signed by Joker, Jonny LPC 11/12/2017 1:00-2:00 PM “Tom identified one trigger – his new medication.”

24. S.O.A.P GROUP NOTE BETTEREXAMPLE Signed by Isle, Isabel ISAS 1/25/19 5:30-7:30 PM Relapse Prevention Group (Relapse Prevention Therapy curriculum). Reviewed and co-signed by Silly Sally LPC S: Tom said he “is tired of always being late” and thinks his new medication is making him “more tired.” He identified this is making him feel triggered to use in order to “get things done.” O: Tom was 5 minutes late to group and apologized to group for being late. His appearance was disheveled which is unusual for him. The topic of group was identifying triggers. A: Tom had difficulty staying focused in group. He may be adjusting to new medication P: Counselor will consult with Tom and his prescriber regarding his medication. Tom will return to group next week to continue working on Tx Plan Goal #1, Obj. 1., Int. 1.

25. FAMILY SESSION NOTES Follow same guidelines as individual session notes SUD Providers - if family is not part of the treatment plan, document why Family challenges often require family interventions

26. NARRATIVE FAMILY NOTE - EXAMPLE Signed by Sally, Silly LPC 11/17/2018 10:00 – 11:00 AM “Ann came to family appointment with her parents, Tim and Joan. They all reported they had been practicing using “I statements” and found it is very challenging but has helped reduce some of the conflict. Tim shared he is worried that Ann may be hanging out with her old using friends again and he recognizes this has made him a little controlling.

27. NARRATIVE FAMILY NOTE (cont.) Ann became visibly angry, started shaking and said in a raised voice “you never trust me and I am sick of it!” Joan began to cry and quietly said “please stop.” Ann was able to use I statements and became calmer. She admitted being tempted to call old friends because she was lonely but denied doing so. She told her parents she had started going to a women’s group at a different church that she was afraid they wouldn’t approve of. They told her they

28. NARRATIVE FAMILY NOTE (cont.) just wanted her to get better - regardless of what church she went to. Joan said she would like to learn more about the church if and when Ann was comfortable with that. Ann thanked her and said “maybe you can come with me at Christmas.” Clinician noted Ann did not storm out today as she has in past when there is conflict. The family agreed to continue to work on their communication and practice using “I statements” per Ann’s Goal 2 Obj. 1 Int.1. Next family session scheduled for 12/5/18 at 10:00.”

29. CASE MANAGEMENT NOTE Signed by Mann, Cassie BA 1/15/19 10:00 – 10:05 CM spoke with Mike Smith, PO, regarding client testing positive on 1/14 for opiates and the voice mail message client had left case manager about possibly being kicked out of housing 11:00 – 11:15 Client dropped by CM office before

30. CASE MANAGEMENT NOTE (cont.) going into group and asked for list of other Safe and Sober Housing providers in Meridian. Client shared he would ask his counselor after group today to put in a request for a transfer to another SSH agency. Client confirmed he would be at his scheduled CM appointment on 1/16/19 @ 3:00

31. CASE MANAGEMENT NOTE (cont.) Signed by Mann, Cassie BA 1/15/19 10:00 – 10:15 Client called CM and shared she had lost her job and didn’t know what to do. CM provided information about and phone numbers to Vocational Rehabilitation and Department of Labor. Client confirmed she would be at group tonight and her scheduled CM appointment on 1/16/19 @ 3:00 to discuss further.

33. ADDITIONAL QUESTIONS? Contact: • BPAQuality@bpahealth.com Or one of the following Clinical Quality Coordinators: • LaDessa.Foster@bpahealth.com • Shayne.Aguirre@bpahealth.com • Lianna.Trembath@bpahealth.com • Lisa.Bell@bpahealth.com • Doug.Hulett@bpahealth.com

34. CE’s At the end of the webinar you will be prompted to complete a brief survey. You will receive your CE certificate via email in the next 2-3 weeks.

35. THANK YOU !