Clinical Documentation
This best-practice standard expects progress notes to be completed collaboratively with the client or by the end of the business day, with agency policy requiring entry within this specific time frame.
What is within 24 hours?
Staff should make sure a client does this before driving.
What is put on their seat belt?
When a client misses a scheduled CPRC service, Community Support workers are expected to attempt follow-up within this time frame and consult with a supervisor to assess client stability and potential crisis concerns.
What is 24 hours?
This type of care emphasizes personal strengths, skill acquisition, and harm reduction while encouraging self-advocacy and active participation in recovery.
What is holistic, person-centered care?
"In psychiatry, if a client misses four appointments within twelve months, they are not rescheduled directly but are instead referred to this service or staff to assess barriers to care and determine ongoing needs."
What is Access to Care?
A structured, short-term, and immediate action strategy designed to assist individuals experiencing acute emotional, mental, or behavioral distress.
What is a Critical Intervention plan?
When approaching a client’s home for the first time, staff should keep these readily accessible for safety.
What are car keys?
A caseworker should involve these two roles to determine if it is clinically appropriate to begin discharge procedures.
Who are the supervisor and the client’s physician/APN?
A key philosophy of community support services is focusing on this aspect of the individual rather than just the disorder.
What are personal strengths?
A client is in CPRC and misses 4 psych appointments in 12 month period or 3 therapy appointments in a 3 month period this person completes Access to care.
Who is the CSC?
This quarterly assessment requires staff to document barriers to services, changes in daily living functioning over the past 90 days, and to update the treatment plan when appropriate.
What is the Quarterly Functional Assessment Update (DLA-20)?
Upon arriving at a client’s home, staff should note the location of these in case a quick exit is needed.
What are exits, including windows?
Caseworkers must make contact with client post psychiatric hospitalization in this time frame
What is 24 hours
These approaches are used to help individuals adapt to environments such as home, school, family, and work when mental illness or substance use has disrupted skill acquisition.
What are interventions for functional skill development?
These may originate inside or outside an organization and involve sharing eligibility and service information with forensic case monitors, public administrators, hospitals, residential care facilities, and other sources to determine enrollment in services.
What are internal and external referrals?
A CPRC treatment plan must be ________ and include this type of goals, along with measurable objectives, obstacles, resources, interventions, and discharge/transition plans
What is person centered
Staff should respect this aspect of the household during a first-time home visit.
What is the family’s personal space?
These are the four key actions a caseworker should take when a client leaves supervision unexpectedly.
What are: briefly search if feasible, notify parent/guardian, develop a plan with them, and notify supervisor?
These approaches are used to promote active participation in decision-making and support recovery through step-wise and motivational strategies.
What are stage-wise and motivational approaches?
According to DMH guidelines, this number represents the maximum number of clients a case manager may carry, though it is not a required caseload and should be adjusted based on client needs.
What is 30 clients?
To meet compliance standards for each rendered service, individual progress notes must fully document not only when and where the service occurred, but also this comprehensive combination of clinical elements that justify medical necessity and guide ongoing treatment.
What are the service provided, actual time rendered, behavioral observations, goal/objective/intervention addressed, specific staff intervention, client response, progress, and the plan for the next session?
During a first-time home visit, staff should observe these cues from household members to monitor potential escalation.
What are physical cues of escalation?
It is the policy of Community Counseling Center, that the initial response to aggression or assaultive behavior will include positive behavioral interventions followed by additional procedures based on facility type. Intrusive interventions, such as strip searches and pat downs, are not utilized in our programs. In addition, the level of training and types of interventions will be determined by program/facility type.
What is non-violent practices?
While positive outcomes include employment and housing, community support services also aim to decrease this, reflecting a legal and social component of recovery.
What is criminality/legal involvement?
This includes, at a minimum: presenting problem and referral source; brief history of previous psychiatric/addiction treatment including type of admission; current medications, current mental health symptoms (must support diagnosis); current substance use; current medical conditions; diagnoses, including mental disorders, medical conditions and notation for psychosocial and contextual factors; functional assessment (DLA-20); identification of urgent needs; initial treatment recommendations; and initial treatment goals to meet immediate needs within the first 30 days of service.
What is eligibility?