Who sees this!?
Why are progress notes necessary?
For purposes of client care, treatment coordination, billing and accreditation
What does page three of a progress note consist of?
Signature
Per CARF standards, notes should include details about the services delivered. Provide an example of how you would write about the services delivered.
Multiple answers- what intervention did you provide and why? What specific techniques did you use, to teach/practice what?
List three commonly used words your position uses when documenting interventions (CM versus TBS versus therapy)
Multiple answers
Who can request/review documentation?
List 2
client, parent, attorney, auditor, doctor, therapist/CM from different agency
Explain what the first page of a progress note consists of and what you must select
Goals addressed- must select at least one goal, corresponding objective, and an intervention
Progress notes should also note any significant changes/events related to client (addressing this in note as well as associated checkboxes)
Identify 2 significant events that you would want to note
Multi answers
What happens/what should you do if you go in to complete a note and find that the treatment plan is expired?
Cannot complete a note with an expired treatment plan, if TP was not reviewed in time with client--this note will have to be made into a memo
Coordinate with therapist
The only documents that can printed and released to clients without completion of the Protected Health Information form (found in Sharepoint) are:
List 2
treatment plans, transition plans, ROIs, safety plans
Page two of a progress note includes checkboxes. Identify 2 of the checkbox topics and explain why they are important
changes in medical, others present, stressors, new issues, mood, affect, thought process, orientation, behavior/functioning, substance use, danger level, follow up
Per CARF standards, notes should include details on client progress towards goals and objectives. Provide an example on how you would write about this in a note.
Multiple answers- give specific details
use "as evidenced by..."
True or false: it is okay to duplicate (copy and paste) notes if you did the same activity before with this client or with other clients
False- Notes should be individualized. Even if the activity was similar, the goals, objectives, and responses will be different.
True of False: It is considered acceptable to "round up" or "add time" when reporting documentation time (length of session) in EHR, as long as it is reasonable
False: this is considered fraud, all times must be accurately reported
Page two of a progress note includes open box (es) for the written narrative. What should go in this box/s.
Should include info on the interventions provided, client response to intervention, and progress toward goals and objectives
Per CARF standards, notes should include details about the outcomes of the services delivered. Provide an example of how you would write about client response/outcome in a note.
Multiple answer- was client engaged/cooperative? what did client say about intervention? Do they understand use of skill? Weer they able to practice it? how?
Provide an example of inappropriate content for a note.
personal judgments, opinions, feelings
Info should be clinically relevant
Fraud is a crime and consequences can include:
List 2
harm to clients/families, job termination, damage to reputation of self or agency, loss of licensure
If you are a case manager and client reports significant life changes/change in goals. What should you do?
Follow up with supervisor/therapist/treatment team to discuss need for TP update or DA update
In what ways should a 30 minute note/session be different than a 90 minute notes/session?
Explain in detail
Multiple answers-you MUST be able to justify your time
Provide insight on a time you had a note rejected. Does your team have any recommendations for writing notes effectively?
Multiple answers