Documentation
At what age would a client be considered an Adult at RE?
What is 18 yo is considered an adult across all services?
If in C&A outpatient services, once 18 yo move to the adult program.
If in APEX 18 yo can stay in program while still in high school.
What are the timeframes for needing a verified and confirmed diagnosis?
What is within 30 days of admission and at least annually by a fully licensed provider?
Outside of the minimum requirements for completing a Crisis and Safety Plan, what are other indicators that a plan should be completed?
What is:
During service the client is assessed at High or Moderate suicide risk
Client is Low risk but reports new stressors or risk factors
During all CSU/hospital BHA follow-ups
When information changes related to the current plan such as risks, stressors, coping skills, support including starting a new service
When lethal means is identified
All of the above
To be allowed to complete the CANS, how often do you need to recertify through the CANS training?
What is annually?
What happens if the door-to-door time for a billable activity is less than 8 minutes?
What is RE will not be able to bill for the service?
If the legal guardian is someone other than the biological parents, what documentation is required?
What is a court order for the child’s legal guardian is required for a C&A admission to be completed?
What is the process for including diagnosis like Autism Spectrum Disorder in a client’s clinical presentation?
What is use the Z Code: z87.898 Personal history of other specified conditions?
What is needs to be formally diagnosed by an appropriate provider
What is the minimum timeframe for completing a SAFE-T with CSSRS Protocol?
What is by a Clinician at every new admission and at least annually?
What do the acronym CANS stand for in child and adolescent test measures?
What is Child and Adolescent Needs and Strengths?
What happens if the door-to-door time for a billable activity is less than 8 minutes?
What is RE will not be able to bill for the service?
If an adult has a legal guardian, who needs to be present to sign documentation throughout services and what documentation is required?
What is the legal guardian must be part of decision-making and signing documentation, along with court order of legal guardianship must be uploaded to the Document Library?
What is the process for including a Remission Specifier for a substance use diagnosis?
What is Add remission specifier to the Severity/Specifier column to the right of DSM-5 Code
When should a client have an alert for suicide risk level on the face sheet?
What is an alert should be created when the client is assessed to be at Moderate or High risk for suicide?
At what age would a client be considered an Adult at RE?
What is 18?
What happens if staff sign a progress note before the End time of an activity and do not adjust the End time?
What is RE will have to pay back the money for units billed after the staff’s original signature time?
What is UM staff must adjust the End time to the staff’s signature time?
What should be one of the first steps in documenting a service?
What is changing the appointment status to Kept?
What are two important components of completing a Person-centered treatment plan?
What is the treatment plan completed with the client and based on the needs identified during the assessment?
What screening tool is used at RE for clients 13 yo and older to screen for early identification, progress in recovery, or continued concern related to risky, harmful, or dependent alcohol use?
What is the AUDIT?
What is used to measure Depression in children and adolescents?
PHQ-9 for children?
How should a clinician document a Non-billable activity?
What is the clinician will schedule the Non-billable activity for 1 minute before the Billable activity anytime while providing their intervention but after the Billable activity has been marked Kept?
ow should the Service Document be completed?
What is always by attaching it to the appointment? (not through the chart)
What are the main components of a treatment plan?
What is Problem Narrative, Goals, Objectives, and Interventions
What screening tool is used at RE to screen, support diagnosis, monitor, and measure the severity of Depression during every BHA?
What is the PHQ-9?
If a client is under the age of 18 yo, who must be present for a C&A admission and the first prescriber appointment?
What is the legal guardian (the parent or other legally designated person)
If a clinician finds they have made an error in documentation after signing or need to adjust their schedule after the date of service, who do you reach out to?
What is Carelogic Billing Admin (CarelogBillingAdmin@river-edge.org)?
What is meant by door-to-door appointment time?
What is the appointment that starts once the client is with you and the status is changed to Kept, then the end time to reflect when the client leaves the appointment?
If a treatment plan needs adjustments but it is still active for more than 30 days, what should a clinician do?
What is use the Update button or the Review button to the right of the active treatment plan to make adjustments?
When screening for suicide risk and a client reported the absence of current suicidal ideation or in the past month, but a history of suicide attempt but not in the past 3 months, what are the potential outcomes for suicide risk level?
What is Low risk if there is support that the client presents with strong protective factors and modifiable risk factors?
What is Moderate risk if there is evidence that the client presents multiple risk factors and few protective factors?
If the legal guardian is someone other than the biological parents, what documentation is required?
What is a court order for the child’s legal guardian is required for a C&A admission to be completed?
How can a Clinician tell if a Connects authorization is needed?
Non-Intensive Outpatient: What is view the Connects section of the chart to see if there is an approved authorization that covers the date of service and does not expire in the next 30 days
CCBHC: What is hover over the Client Menu> Authorizations/treatment documents>Authorizations.
Is there a T1040 code
Does it cover the date of service with enough units to cover service
Extra bonus point- It is best practice to add this to your favorites.
What should you do if your appointment is on your schedule for 9 am to 10 am, but you signed your service document at 9:50 am and the client left at 9:45 am?
What is adjust the End time to reflect when the client left at 9:45 am?
How many treatment plans should be active in outpatient services?
What is a client should only have 1 active treatment plan?
When screening for suicide risk and a client reported active suicidal ideation in the past month without method, plan, or intent, what are the potential outcomes for suicide risk level?
What is Low risk if there is support that the client presents with strong protective factors and modifiable risk factors?
What is Moderate risk if there is evidence that the client presents multiple risk factors and few protective factors?
What does the acronym CANS stand for?
What is Child and Adolescent Needs Strengths
What should a Clinician do if an Approved authorization covers the date of service but the authorization does not have enough units to cover services before expiring?
What is complete an Update authorization from the approved authorization?
What is the process for documentation when a substance use concern or potential concern is identified?
What is document that substance use services and resources were reviewed with client, client response (declined or requested services), and your next steps (declined-encouraged client to follow-up if needs change or accepted- made referral, discussed process)?
How often does a diagnosis need confirming?
What is Annually?
When should a client have an alert for Suicide Attempt History on the face sheet?
What is an alert should be created when the client is assessed to have a history of a suicide attempt?
What is the youngest age for children to participate in the APEX program?
What is all children K-12?
If the ASO approved diagnosis attached to the authorization is Mental Health only, what should the Type of Service (TOS) be for the authorization to be approved?
What is TOS MH only?
If the ASO approved diagnosis attached to the authorization is Mental Health only, what should the Type of Service (TOS) be for the authorization to be approved?
What is TOS MH only?
When should a treatment plan be signed?
What is the same day of service and completed with the client?
What does the acronym CSSRS stand for?
What is Columbia- Suicide Severity Rating Scale?
What is the most appropriate therapeutic approaches used with Adolescents?
What is Person Centered approaches?
If the Type of Service (TOS) for an authorization is MH/SU, what diagnosis(es) need to be in the treatment diagnosis document attached to the authorization?
What is an ASO approved Mental health and Substance use diagnosis?
What are the main components of the Problem Narrative?
What is the Transition/discharge, Clinical benchmarks, and Expected end date
How often is a Treatment Plan Review completed for clients receiving services in outpatient?
What is every 90 days in Mental Health outpatient from the last treatment plan or last treatment plan review?
What is every 60 days in Substance Use outpatient from the last treatment plan or last treatment plan review?
Outside of the minimum requirements for completing a SAFE-T, what are other indicators that a SAFE-T should be completed?
What is:
During service the client is assessed at High or Moderate suicide risk
In a follow-up appointment after a client was assessed at High or Moderate suicide risk and now assessed at another risk level (High to Moderate, Moderate to High, High or Moderate to Low)
Client is Low risk but reports new stressors or risk factors
During a CSU/hospital BHA follow-up if the client’s admission was related to High r Moderate risk
Whenever a clinician wants to use it to support decision-making
All of the above
How often is the CANS completed in Child and Adolescents or APEX?
What is every C&A admission?
What is every 6 months in the APEX program?
If you find you have made an error in your documentation but have already signed the document, who do you reach out to?
What is Carelogic Billing?