Assessment
These two sections in the BHA must always be written from scratch
What is the Presenting Problem and Clinical Formulation
These are considered "lock-out" settings (must give at least 4 examples)
What is a hospital, crisis house, jail, IMD, SNF
When you speak to a client and then the landlord during your visit, you should do this when writing notes
What is, write two separate progress notes
This document is required any time a client has discharged from an inpatient facility for DTO or DTS, ideally at the 48 hour follow-up appointment.
What is the HRA?
This is how much service time you can enter when a client No Shows or Refuses a service
What is 0?
This BHA section must include justification for diagnosis and medical necessity. It should also describe the client’s impairments and proposed plan of care. Per CARF requirements, CRF also documents SNAP in this section.
Clinical Formulation
These 3 things are needed in every billable progress note
What are symptoms, functional impairments, and interventions?
This is required when billing time is :47 min however the notes states, "met with client, assessed for safety, and reviewed coping skills..."
What is, substantiate your billing time? Explain why it took so long with clinical interventions and client response.
These are 3 examples of coping skills a client can use that you would include on a My Safety Plan
What is what
- Listen to music (list which song or which radio station to play)
- Take a walk (where are they walking)
- Specific self soothing techniques
- Call a support person (list which person)
- Talk to me (about what)
- Any other CLIENT SPECIFIC example
This is the type of note you write when scheduling an appointment is the main objective.
What is a Never-Billable (Informational) note?
In this section of the BHA, all prompts must be completed (even if you are unsure, you can document "unknown", or "N/A") to be complaint for a chart audit.
What is the Substance Abuse Information section
This is what you should write in your progress note when speaking to a support person who the client consented for us to speak to
What is "ROI on File"?
This is never allowed when entering billing time, unless the time is accurate. There should be no pattern of this found.
What is rounding?
Ongoing Risk Assessment in a progress note should include this for SI and HI.
What is client quotes or a detailed explanation as to why you as the clinician feel the client is not currently at risk?
When the Place of Service is where the Client is
What is a lock-out setting? (hospital, crisis house, IMD/SNF, jail)
This symbol indicates that consultation with a licensed supervisor is needed.
What is a starred item on the PRA
In order to justify a 34 Rehab note, you must include this
What is an evidence based practice (specific therapeutic intervention) ex: MI, CBT, DBT, Seeking Safety...
This service is considered rehabilitation service to a support person. It must include a description of the client’s impairments, and how the support person will address the impairments or support the client in meeting their goals/objectives. Progress note must document both the clinician’s input and the response of the recipient Must be two-way communication!
What is a 33, collateral?
These are 2 examples of what a clinician would add to a My Safety Plan if the client is unable to identify any Early Warning Signs
What is
- When voices/depression/anxiety increases
- Treatment team observes that client will isolate, not meet with the team, become agitated, increase substance use, have increased SI, doesn't talk to family...
This is the Appointment Type you would indicate if you called a client on their scheduled day and left a voicemail
What is a No Show?
In addition to considerations and demographics such as language, religious/spiritual beliefs, socio-economic background, ethnicity, race, age and subculture; this must specifically be documented within the Cultural Information section of the BHA.
What is the impact of culture on the client’s mental health, perception of symptoms or access to services
When you transport a client to a MediCal provider site you must bill for it this way
Write a separate 815 note to capture the travel time.
These are the service codes you enter when a billable 50 and 34 note are being entered past 14 days. You must give both service codes.
What is 800 (non-billable case management) and 802 (non-billable rehab)
This is what you should do when a client has either reported an increase in opiate or methamphetamine use or recently had an incident regarding those two substances.
What is link client to MAT (Medicated Assisted Treatment) resources?
This is the Intensity Type you would select if you are Bilingual clinician and you provide the service in English
What is N/A?