Documentation
Treatment Planning
Mental Health
Case Management 101
Potpourri
100
This billing code is used when documenting a phone call with either a client or collateral contact.
What is a CPST
100
This is the number of visits/days you have to create a new treatment plan upon transfer or start of service.
5 visits/30 days
100
This professional is licensed to diagnose mental health disorders and prescribe medication.
Psychiatrist
100
This quadrant is used to describe "More Severe Mental Health and less severe Physical Health/Substance Use".
BH LOC II
100
Per best practices, when a client misses a scheduled psychiatric appointment you should attempt to contact and engage the client within this number of hours.
Twenty Four Hours
200
This can be referred to as "the consistent and coherent connection of relevant clinical information through-out a client's documentation, and ensures that all elements of care are aligned and traceable.
The Golden Thread
200
These are specific, measurable steps on a treatment plan that help a client achieve their goals.
Objectives
200
This is a set of verbal and non-verbal techniques used to reduce the intensity of conflict. It often involves active listening, empathy and maintaining a calm demeanor.
De-Escalation
200
This case management function focuses on identifying client needs, strengths, and barriers.
Assessment
200
This is what LAI stands for.
Long Acting Injectable
300
This follows the behavioral observations and interventions provided in a case note and reflect the client's reaction to the visit.
Client's response
Client's progress
300
This is how we document a guardian's involvement in the treatment planning process.
Signature on plan
Attachment of all correspondence sent to guardian
300
This serious mental illness is characterized by disturbances in thought, perception, and functioning.
Schizophrenia
300
This activity ensures services are coordinated across providers to avoid duplication of or gaps in service.
Service Coordination
Care Coordination
300
When a case manager shares information with a third party and/or another provider to coordinate care, this law must be followed.
HIPAA
400
A progress/case note that accurately describes the service, but does not connect it to the treatment plan goal is missing this required element.
Medical Necessity
400
This is the appropriate "modality" listed on all regional case management treatment plans. This describes the TYPE of service being provided.
TBS/PSR
400
This term describes a return of symptoms after a period of improvement or simply "falling off the wagon".
Relapse
400
This is the document a client signs to authorize CSS to provide services to them.
Consent for Treatment
400
A: Motivational Interviewing
500
Trauma Informed Care
500
This proves that the client was actively involved in the treatment planning process.
Client/guardian signature, quotes, accompanying note state client actively participated.
500
This symptom includes hearing or seeing things that others do not.
Hallucinations
500
When updating a treatment plan, these four assessments should be updated either annually or every six-months for all clients.
NOMS
AUDIT
PHQ9
DLA 20
500
Upon discharge from a psychiatric hospital, a case manager should make contact with the client within these many days of discharge.
2 days