Assessments
Q: When are assessments due?
Within first 30 days of treatment
When are treatment plans due?
Within the first 30 days of treatment
When are DAP notes due?
Within 24 hours of the session
What is the age of consent for mental health treatment in NM?
14 is the age of consent for mental health treatment in NM
Oh no! It looks like your assessment will be submitted late. How should you document this?
Note under “General Notes” why it is late (client in crisis, client missing sessions, etc.)
What is the minimum amount of goals insurance companies look for on a treatment plan?
3 long-term goals
Where does additional documentation go in the clients file?
Document manager
What is the typical length of time that an ROI is valid for?
One year. Remember to update ROIs every year if the client wants ongoing communication with an external resource.
What should be included in the section “Interviewer’s Assessment?”
A summary of the client, including presenting problem, goals, and any important observations about the client (i.e. presentation, motivation, stage of change).
When are treatment plan reviews due?
Every 90 days
What does DAP stand for?
Data, Assessment, Plan
When referring a client out or to a higher level of care, how many referrals do you have to give?
3 referral sources
True or False: You have to complete separate assessments if a client sees you for individual and another therapist for couples.
True: Yes, assessments required for each type of therapeutic work (couples, family, individual).
Where can you note that the client was engaged in creating treatment plan goals?
2 answers - Under “General Notes” or capture the client’s signature
InSync auto populates a session’s start and end time to be exactly 60 minutes. True or False it's okay to leave it this way.
False: Exact start and end times on the hour can be a red flag for insurance companies that there may be other issues. History of insurance companies claiming fraud by providers due to inaccurately reporting session times.
Who are discharge summaries sent to for co-sign?
Ilse
What EHR do we use for documentation etc.?
InSync
What are SMART goals?
Specific, Measurable, Achievable, Realistic, Timely
Client cancels without 24 hour notice because they forgot about the session. How should you document?
Unless it's approved by Daniel it's considered a "no-show"
What is the purpose of clinical documentation?
Ensuring continuity of care, Legal and ethical obligations, improving patient outcomes.