Clinical Notes
CBT, DBT, Play Therapy, Person Centered, CPT, Solution Focused, are all examples of what?
Modalities
When writing an assessment you are trying to prove that the service are what?
Clinically Necessary
How should your goals be written?
As Smart goals
How much time should be between each ISP review?
6 sessions or 90 days, which ever comes first
What is the amount of time you have to do a note?
24 Hours
Name 3 things you would include in the behavior section
Counselor observation, Mental Status Exam, Client brief statement
When completing the symptomology section you need to gather what?
The most information possible
What does SMART stand for in SMART goals
S: specific
M: Measurable
A: Achievable
R: Realistic
T: Time Bound
What is the first thing you should include in a response to an ISP review?
What the client has worked on with the clinician during this quarter and or Barriers to this goal
Clinician, client and guardian/parent, Yes
What section would you put these examples?
Role playing, Guided Discovery, Skills Training, Reframing, Radical Acceptance, RULE, OARS, Scaling Questions, Miracle Questions
Intervention Section
When writing the summary what are the three sections you need to include?
Demographics, Diagnosis with supporting symptomology, and recommendations
How should your goals be written?
Person centered in a way that the client can understand the goal itself
What is the second thing you include in the response to the review?
What you plan to work on during the upcoming quarter
What is the turn around time for ISP's and Assessments?
ISP's: 1 day
Assessments: 2 Days
In this section you would speak about how the client responded to the intervention, progress made to goals, treatment planning, requests made.
Response section
How do you correctly utilize a previous assessment?
You state "per the previous assessment completed on date by clinician name and either summarize or add quotations
If your client has a MDD diagnosis what must you have in your ISP?
Safety Goal
What is the third thing you include in the response portion of the ISP review?
The client/parent's thoughts on the progress of the goal
How long do you have to get a signature on oncall?
15 business days
Do you put anything in the "additional risk assessment information" box if there was no additional risk assessment information needed? If there was what would you put?
Can you provide a ADHD/and or Autism diagnosis without a psychological to support it?
Yes, according to the CSB, if the client meets the DSM criteria for the ADHD diagnosis we can provide a ADHD diagnosis but it needs to be a rule out. We can also add a Autism Diagnosis if they have a history of Autism diagnosing however we need to request documentation, IEP or psychological. Refer for a psychological for both diagnosis
All clients must have this on their ISP's? But only fall risks need this?
A discharge goal, fall risk goal
Who signs an ISP review?
The client, parent and or guardian, clinician and supervisor
Before you can complete an annual assessment what must be done first?