A360
List the components that should match in the service activity and mental health specific service detail
Date
Provider
Identifier
ICI
What assessment measures do you utilize in a reassessment?
1. STRESS
2. any others administered at intake (TSCC/TSCYC, PSC-17/Y PSC-17,
3. any others deemed clinically appropriate
Do you complete a Mental Health Intake write up if you screen a sibling?
Yes, if they qualify for services and you did a follow up assessment
Who is responsible for conducting file audits?
The clinician. The supervisor conducts monthly file audits but is unable to review every client file.
What needs to be completed at the data deadline?
All mental health service activities and document uploads from the previous month
Exiting clients/audits for the month
Mental Health Data Checklist
Weekly numbers log for the month
What do you use the print function for in A360?
File Audits
Reviewing session notes
What should you update when reassessing
Diagnosis (when applicable), treatment plan
!!!!!!DOUBLE JEOPARDY!!!!!!
Where do you document a sibling screening
AND (for bonus points) what is the process of sibling screenings
In the siblings file
Process:
Initial brief screening with primary client's CG
Find a Provider
Full assessment of Sibling (STRESS 1 and 2)
Intake write up
How often do you conduct a comprehensive file audit?
Minimum at start, mid, and end of treatment
What are the things you would correct when auditing a file?
Dates, Numbering, signature, a missed checked box/radio button, missing note, missed document upload
What are the components of your service activity identifier?
Treatment Modality Session #:Component/Phase
Reassessment (if applicable)
No Show/Cancellation # (if applicable)
Telehealth
How often do you reassess?
every 90 days
as clinically appropriate
every 6 weeks for PSB
If family members attend a graduation session, what is your documentation responsibility?
Gather birthdate, phone number, and demographic information
Create profile and connect ICI's
Document as you would a caregiver participating in session
Name two parts of the file you should be tracking and updating while the client is in treatment
Treatment Plan
Diagnosis
Consent paperwork
What are the components of a comprehensive file audit?
Staff and Program Assignment
Confirm demographics
Document and consent uploads - Confirm up to date
Check Service activities for numbering, matching dates with MHSSD, and signatures
Read through MHSSD to check nothing is missing (dates, notes, etc) and confirm continuity between sessions
What are the steps to utilizing the Print function in A360
In Client's file, press the 'Print' button at the top right corner of the file. Once the box appears, click the subsections you wish to review/print and scroll down to 'print'.
When looking at a file, how do you identify the reassessment?
Click the radio button in MHSSD
write 'Reassessment' in identifier
When would a caregiver not have a note matching the client's file?
When a caregiver did not attend the session or in specific modalities such as CFTSI or Parenting Group
What is your responsibility in the file when you get a new client?
Ensure the Staff Assignment is updated
Check Consent Paperwork
When do you administer the Mental Health OMS
When services are ending - this could be when the client graduates or is ending treatment for any reason
What types of identifiers in documentation should be numbered, and why is it important to keep that numbering consistent across notes?
The session number
The No Show/Cancellation number
.....Consistency Importance.....
What are components to include in the reassessment note
SOAP Format
Current Reassessment Results
Past Assessment/Reassessment Results
Clinician's assessment of results
Diagnosis Update if applicable
Clinical Recommendation/Plan
How should you document a session if two providers, two clients (siblings), and their caregiver attended a session together?
Each provider does the documentation for their own client and one provider documents in the caregiver's file. The providers communicate about how to document future caregiver conjoint time.
What elements of a file would you review when subpoenaed for court?
Intake assessment - presenting symptoms and diagnosis
Treatment Notes - client's progression in treatment
Exit reasoning - graduation or dismissal cause
Name two elements that should show clear follow-up or continuity in your clinical notes from week to week.
Homework
Safety Planning/safety check-in
Session component planned
Finishing an activity otherwise stated as incomplete
Follow through on consultation