Documentation and Records
The compliance time limit for completing progress notes shares a name with this 2008 Matisyahu song.
What is "One Day"?
This "minor detail" should always be included in methods for clients under 18.
What collateral sessions? (Include method!)
Switching from Z45 to A45 may mean you need to manually include this section.
What is the audio-only declaration?
Using ELEOS regularly will not make our job easier or save us valuable time as therapists. It is not a way to allow us to train more, see more clients, or just chill more.
False. It can actually do all those things. Quite efficiently, too.
This important note type shares its name with a fun family game requiring only 3 people and some sharp wit.
What is a contact note?
"I've fallen, and I can't get up!", would theoretically be entered in this section of the treatment plan, and is always a required field to complete.
What is the "specifics for this problem" section?
Justification for audio sessions must be "dually noted" in these two documents.
What are progress notes AND treatment plans?
"I'm having a 'good face for radio' day" is a good justification for a therapist to request an audio session.
False. Radios don't have faces.
Also, audio sessions have to be by client's request.
Access to ANY client records or personal health information is only allowable under these conditions.
What is a "need to know" basis?
The 6-month treatment plan due date refers to the signature of this individual. The clinician signature is due two weeks before.
Who is the psychiatric provider?
"Where the client is at" can refer to a client's readiness for change or this important telehealth documentation detail.
What is "client's location"?
When documenting a telehealth session, it's ok to estimate or adjust the start and end times.
False! Zoom logs must match the IMA documented session time. Adjusting sessions times or duration could be construed as fraud.
This phrase suggest that therapists have the ability to control reality through documentation.
Having this kind of session regularly must be clinically justified in the treatment plan.
What is a very short session?
This must be shown and documented in every telehealth session even if you know the client personally.
What are two forms of identification?
It's best practice to double-check the latest available diagnosis from the psychiatric provider before signing off on a treatment plan.
True! Keeping things consistent across the case helps inform treatment.
This evaluation shares a name with a 24-note bugle call written by Brigadier General Daniel Butterfield and may suggest follow-up evaluations that need to be done.
What is TAPS?
A client reports on intake that she will not be able to have in-person or Zoom sessions regularly, as she lives in a submarine in the Hudson River. Her submarine has no WiFi. Her preference needs to be recorded in this treatment plan section.
What is the "Service Delivery" section?
This is the most common phrase heard on telehealth sessions
What is "Can you hear me?"
Clients must be seen within a specific time frame following a psych/SUD hospital discharge.
True! We have 7 days to see a client coming out of this situation.