Safety Plans
Congratulations! You assisted a patient in completing a Danger to Self Safety Plan. In what 3 places should this be documented?
1. DTS/DTO Tracking Log
2. Psychology/AD/TSSC Progress Note
3. Patient Education Record
When completing a refusal note, what should always be included?
The reason the patient refused or did not attend group.
What is wrong with this presentation sentence?
Pt presented with depressed mood and congruent affect AEB rapid speech, upright posture, and intense eye contact.
The mood is not evidenced by the behavioral observations.
Write an appropriate presentation sentence of Tony Soprano in this session:
Pt presented with anxious mood and congruent affect AEB avoidant eye contact, resistant attitude toward therapy, and occasional tapping of his foot or hands.
You have completed filing a report with Child Protective Services on behalf of a patient. What should ideally be the title of the progress note documenting this process?
Psychology & AD Note / CPS Report
What is wrong with this note title?
Psychology & AD Note / Danger to Self Safety Plan
It does not mention if the safety plan was completed or attempted.
How can this part of a group therapy progress note be improved?
In response to prompt to identify their primary coping skill, Pt said, "I like weed!" Facilitator validated Pt's response and encouraged Pt to continue to attend groups.
The Facilitator's follow-up does not adequately address the Pt's response. Ideally, the documentation should reflect some type of challenging or re-framing of a potentially harmful coping skill.
What are three elements of informed consent that should be reviewed and documented in an initial individual therapy session?
1. Nature of therapy
2. Limits of confidentiality (including mandated reporting)
3. Writer's trainee status
Write an appropriate presentation sentence of Tony Soprano in this session:
Pt presented with depressed mood and restricted affect AEB slumped posture, perseverative thought process, and frustrated verbal content.
If a patient refuses individual therapy despite there have been a face sheet created for them, how should you proceed?
Document the refusal and state that Writer will continue to check in with Pt periodically while they remain in hospital via supportive stabilization.
How would you proceed if a patient with whom you are completing a safety plan responds to a majority of the prompts with seemingly delusional content (e.g., "My main coping skill is knowing where all the cameras are!")?
If the patient cannot provide responses more grounded in reality, then document the safety plan as an attempt due to the patient being too symptomatic. Include in documentation a plan to assess further as patient stabilizes. DO NOT mark as completed in DTS/DTO Log.
SUPERVISOR JUDGE QUESTION!!
You tell the patient in group about API outpatient programs, AA, Smart Recovery, and the evidence suggesting that the longer a person remains in some type of recovery program the longer they stay sober.
How might you document this as a "plan" in your progress note?
(Judged to be correct or incorrect by one of our clinical supervisors.)
How might you document the following:
A patient in individual therapy says they often think about not waking up in the morning, but they don't actually want to kill themselves.
Pt expressed passive SI without means or intent.
Write an appropriate presentation sentence of Tony Soprano in this session:
https://www.youtube.com/watch?v=-BmNAxi7xF0&list=PLQXk9_XDN67I-LLha7BJ7YExVSTeD0gbP&index=26
Pt presented with euthymic mood and congruent affect AEB positive verbal content, relaxed posture, and use of humor.
What is one reason why it may be important to be mindful of objectivity and specificity when completing documentation?
If the patient were to ever request their records or if the records were to ever be subpoenaed for court, there is possibility that overly subjective or unnecessarily specific documentation might be harmful.
Name three things that should be included in a completed safety plan progress note that would not necessarily be included if the safety plan were not completed.
1. A brief summary of how the patient responded to questions on the plan.
2. Whether the patient requested a family involvement session or not.
3. Documentation about the patient receiving a copy of their completed safety plan.
How might you improve this documented intervention for a group focused on Distress Tolerance?
Facilitator asked Pt to identify their spirit animal. In response, Pt said, "My spirit animal is a snake!"
Ideally, the intervention should be more aligned with the group topic. For instance:
Facilitator provided DBT-based psychoeducation about "urge surfing." When asked to identify a real-life example of "urge surfing," Pt said, "Waiting until patio break to have a smoke!"
What are 4 possible criteria for hospitalization?
1. Need for medication stabilization
2. Recent SI or HI
4. Risk of decompensation if transferred to a lower level of care.
4. Inability to verbalize a plan to provide food, clothing, or shelter for self.
Write an appropriate presentation sentence of Carmela Soprano in this session:
Pt's wife presented with anxious mood and labile affect AEB guarded posture, tearfulness, and facial tension.
For Addictive Disorders, if you are completed a Psych Consult with a patient who is detoxing, what should ideally be included in the documentation (assuming it was done)?
A detox follow-up, which states how Writer checked in about Pt's current withdrawal symptoms and if any psychoeducation or resources were provided.
Name 4 mistakes made in this one sentence:
Writer met with Pt to complete safety plan.
1. It does not designate when or for how long the meeting took place.
2. There is no location indicated for the meeting.
3. The type of safety plan is not specified.
4. Technically, this sentence makes it sound like the writer is completing the safety plan.
A patient does not say anything in a process group (though they do seem to be laughing or getting frustrated at random times). Facilitator pointed out that Pt appeared to be listening well to others and sometimes nodding in agreement, even though Pt didn't actually look up at anybody and couldn't stop shaking their legs.
Write an appropriate group progress note!
Writer facilitated process-based group focusing on current thoughts and feelings of group members. Pt presented with anxious mood and labile affect AEB psychomotor agitation (e.g., legs shaking), downward gaze, and responding to internal stimuli. Pt passively participated in group discussion. Though Pt did not provide any verbal content, Pt nodded in agreement in response to another group member sharing their feelings. Writer praised Pt's listening skills and encouraged Pt to continue to provide support for peers.
Aside from behavior, intervention, response, and plan, what are 4 necessary elements of an initial individual therapy progress note?
1. "Per psychiatrist's order"
2. Review and provision of informed consent
3. Assessment for SI/HI
4. Criteria for hospitalization
Write an appropriate presentation sentence of Tony Soprano in this session:
Pt presented with depressed mood and incongruent affect AEB slumped posture, negative verbal content, and smiling.
What is likely the number one reason for mistakes in documentation?
Not double-checking after it's completed!