Annual Documentation
How far in advance can annual paperwork be started?
60 days before it is due.
How often is the MichiCANS due?
Annually, as major updates arise, or to determine LOC.
What does the “Golden Thread” mean in treatment planning?
The goals should clearly connect back to the needs and clinical information identified in the assessment.
For individuals over what age is the PHQ-9 recommended at least quarterly?
Over age 11.
Where should progress notes and non-billable contact notes be started?
Through the calendar appointment.
Which ROI's need to be completed at an annual?
School, PCP, Emergency contact, 5515 (Combined Consent to Treat/ OCHN/Common Ground/NO). If need be: ancillary services, CPS, foster parent, specialty doctors.
Given these outcomes on the DSM for your MichiCANS, would this individual be IOP or COP Level of Care?
NSSI
School Needs (School Achievement or Behavior)
Unhealthy Family Dynamics (Family Functioning)
Decision Making or Anger Control
IOP
"Summer will meet with clinician 2x per week" belongs in what section of the IPOS?
Interventions!
How often should the Crisis Plan be completed/updated?
At least annually. Otherwise: within 30 days of hospital screening.
When writing goald and objectives in the IPOS, where should we use Quotes from individual/family?
Goals only. Objectives are the measurable part and do not need quotes.
Is a Combined Consent to Treatment valid if it is in the chart, but not signed by the appropriate party?
No. It must be signed by the appropriate party or uploaded with signature to the correct place in the chart.
Which 3 Stand Alone Assessments could be completed for the Behaioral/Emotional Needs Domain?
PHQ9
CRAFFT
GAD 7
How would you make this objective strength based?
I want to reduce my angry outburst from 4x a week to 2x a week.
I will utilize at least 1 of my 5 learned coping skills when feeling frustrated or angry as situations arise or 5 out of 7 days per week.
If an individual answers “yes” to one of the first two suicide-risk questions, what should happen?
Complete the full SAFE-T. and CSSR-S questions.
During the annual, you identify a need for Respite. What additional workflow should occur?
If OP, send a To-Do to the CM to complete the Respite assessment and schedule Goal/Objective Training as applicable. If HB, HB clinician completes.
What are the three reasons you would do a goal/objective training during the annual workflow?
To train peer support, parent support and/or CLS/Respite worker.
If an individual/family shares that the individual has run away from home once or run from a treatment setting, which rating would you give that item?
2: Need or risk is interefering with functioning, action is required to ensure that the identified need or risk behavior is addressed.
During the assessment, the family identifies housing instability as a major concern. What should happen to that information if it remains an identified need?
It should be addressed in the goals and, when applicable, the Crisis Plan, maintaining the Golden Thread. Referral for CM services.
Someone is on the High-Risk or Zero Suicide Pathway but answers “no” to the first two suicide questions today. Do you still need to update SAFE-T?
Yes. SAFE-T should be updated at least every 30 days for individuals aligned with either pathway., until they are removed from the pathway.
A client cancels an appointment. What documentation is required?
Select the appropriate cancellation/no-show response and complete a non-billable contact note or progress note, whichever is applicable, to document the cancellation/no-show and outreach attempt. Start MIA protocol if applicable.
What is the most important document in the annual workflow?
Consent to treat.
When completing an annual micans what are 4 topics that must be in the summary section of Life Functioning?
Intro sentence with name, age, and demographics.
CPS involvement details if applicable.
History of prior services.
Current medication(s) and allergies.
Medical diagnoses
School name, grade, IEP/accommodation, school needs.
Literacy level.
Presenting needs.
Include any relevant information from the Self Health Assessment.
Description of the family and household.
You complete a PR and forget to check the goals and objectives before signing. What happens?
The goals/objectives do not save and disappear from the PR. Once the document is signed, it cannot be fixed, and the PR will appear as though there are no goals/objectives.
What situations would require an Incident Report?
Serious Injury or death
Suspected abuse or neglect
Accident or illness that requires hospitalization
Displays of serious hostility
Attempts at self-inflicted harm or harm to others
Instances of Destruction of property
What is the general difference between a progress note and a non-billable contact note?
Progress notes are generally used for appointments/sessions over 15 minutes; non-billable contact notes are for indirect or direct contacts less than 15 minutes (which includes: case consult, coordination with outside agency, phone call with parent/other).