Clinical Documentation
All documentation for one month must be put into the system by at least this many days after the service date to receive any productivity credit.
What is 10 days?
For billing purposes these dates must match.
What is assessment and diagnosis?
The functional assessment used to facilitate treatment planning.
What is CANS?
Several billable services enable SBT to obtain productivity hours.
Crisis
MHC
Psychoed
Fam therapy
Individual therapy
Assess
After this many days of a treatment plan expiring no services can be provided, not even a crisis.
What is 90 days?
When you are first working with a client, it is reasonable to identify building rapport as the goal for these many sessions.
What is 3?
What is the Wellstone financial form.
Assessments are billed at a minimum rate and must not exceed this time.
What is 90 minutes?
The center is held to a productivity expectation. Each program different than the next, school-based productivity goal is.
What is 74 a quarter?
Done on or before the day that the Tx Plan is done.
What is CANS?
Your progress statement should not just be limited to “good” or “adequate” or “poor,” you will need to support your claim with this.
What is objective evidence?
This is where you should update client change in address or phone number.
What is Update in form Update Client Data, Parent/Guardian Information, and Emergency Contact (as indicated)?
The integrated summary should consist of a brief summary following this template.
What is SCHOLAR?
This is where you add client’s school etc.
What is Admission Outpatient Form?
Three things to do if a client is High Risk.
What is Contact every 30 day, Create client alert, and Update tx plan (if necessary to include high risk behavior)?
Concurrent documentation of services is ideal. Nevertheless, documentation completed within this many days of the service performed is reasonable.
What is 3-5 days?
School-based clients information is shard with districts for data purposes, and to consult and share information.
What is ROI for the school and collateral provider.
The integrated summary has these 3 parts.
What is 1) A brief narrative of what happened in the assessment, 2) Your clinical impression with supporting dx, 3) “Client/client's guardian wants client to participate in therapy and medical intervention to mitigate symptoms. Staff with Dr. Klassing for Psych eval; build rapport; behavior mod; decrease problematic symptoms; Improve insight, communication, and coping skills.” i. Only include highlighted portion when it applies.
The client should be signing in for each service. This is proof that we provided services.
What is medicaid sign in log.
A Tx plan, if the client has medicaid insurance must be reviewed.
What is every three months.
The idea that each piece of documentation should flow logically from one to another so that a reviewer can see the connection, the overall narrative of the documentation.
What is the Golden Thread?
Forms must be updated in order for clients charts to be in compliance. These items are updated yearly.
Tx plan
ROI
Med log
Allergies
Substance Hx table
Al State form
The intake process consist of multiple documents that are required in order for us to meet Medicaid standards.
What is
ADMIT PAPERWORK:
ROI
Statement of right and protection
Statement of understanding
Financial form (and)
Med log
Allergies
Substance Table
Dx
attending pract
Assessment
Parent guardian information
Emergency contact
Al state form
Possibly CANS/Tx Plan
We are not permitted to diagnose these dx by the department of mental health and we are not certified to treat other dx and others do not rise to the level of severity to justify treatment.
What are autism, and R-codes?
Discharge planning is a cookie cutter, that should bee typed in word for word.
What is Medical:
Consult with psychiatrist/PCP Psychiatric: Consult with psychiatrist/PCP Vocational/Educational: Consult with family, school counselor/administration Family/Social: Consult with family, school counselor/administration