Confidentiality
What form needs to be completed and signed prior to information being released?
Release of Information (ROI)
What does BIRPP stand for?
Behavior, Intervention, Response, Progress, and Plan
Clinicians!!
MHP utilized client centered treatment to engage and build therapeutic alliance in the intake session. MHP explained confidentiality and exceptions to confidentiality as well as provided written information and verbal explanation of Cl rights, responsibilities, grievance policy, court related fees, licensure disclosure, recording/photography policy. Guardian was provided with the fee agreement indicating actual expenses, as well as given information on HIV/AIDS and testing sites. MHP and Guardian discussed options for services and how FCS can help Cl and promote a sense of hopefulness for recovery. MHP gained informed consent from parent/legal guardian in session. MHP and Guardian explored reason for seeking. MHP educated on Cl/Guardian role in supporting care plan. MHP engaged Cl and Guardian to complete I-EVAL. MHP assessed for and offered tobacco cessation and substance use resources. MHP assessed for risk for TB and offered resources as appropriate. MHP provided for ongoing strengths-based needs assessment to identify history of needs, future needs, aspirations, help client move towards self-sufficiency and community integration. MHP assessed for SI/HI/NSSI/AVH.
MHP reviewed risks and benefits of treatment.
Caregiver reported Cl had a tough day at school.
Caregiver is not specific enough
Disclosures should always be the ______ for the purpose intended.
Minimum necessary
When you document you assessed for wellness/wellness practices, what should be the main focus?
Physical wellness
What assessment do you complete with the Cl if they report they want to hurt somebody else? Who signs the form
Danger to Others.
Clinician and Clinical Supervisor
MHP utilized client centered treatment to engage and build therapeutic alliance in the intake session. MHP explained Cl rights, responsibilities, grievance policy, court related fees, licensure disclosure, recording/photography policy. Guardian was provided with the fee agreement indicating actual expenses, as well as given information on HIV/AIDS and testing sites. MHP and Guardian discussed options for services and how FCS can help Cl and promote a sense of hopefulness for recovery. MHP gained informed consent from parent/legal guardian in session. MHP and Guardian explored reason for seeking treatment as well as benefits and risks of treatment. MHP educated on Cl/Guardian role in supporting care plan. MHP engaged Cl and Guardian to complete I-EVAL. MHP assessed for and offered tobacco cessation and substance use resources. MHP assessed for risk for TB and offered resources as appropriate. MHP provided for ongoing strengths-based needs assessment to identify history of needs, future needs, aspirations, help client move towards self-sufficiency and community integration. MHP assessed for SI/HI/NSSI/AVH.
Confidentiality and exceptions of confidentiality.
Clinician engaged Cl in session to provide psychoeducation on trauma and abuse and explore current understanding of common impact of these experiences.
Modality is missing
What should your physical safeguards be for Cl's paper/physical records?
Locked twice is best practice, locking file cabinet
What is the agency policy to complete notes by?
24 hours.
What is the timeframe to complete a CCP that is NOT expired?
5 business days, 7 days.
Cl and parent/guardian were responsive to interventions in session AEB talking openly with Clinician, making eye contact, and providing information relevant to treatment. Cl and parent/guardian appeared to understand paperwork which was explained and signed via DocuSign via email provided by Guardian. Cl and parent/guardian discussed reason for seeking treatment. Parent/Guardian appeared to agree that treatment was in the best interest of the child. Cl and parent/guardian requested resources for: OR Cl and parent/guardian denied needs for resources at this time. Cl and Guardian deny exposure to or need for TB resources at this time. OR Cl and Guardian endorse need for TB resources at this time.
Denying or endorsing tobacco/substance use
MHP utilized Trauma Focused Cognitive Behavioral Therapy to engage Cl session activities to identify and process their trauma narrative.
Trauma Narrative
What goes in the title of an email that you are sending to a third-party that has Cl information in it?
"encrypt"
Which of these are therapy buzz words?
A. Identify
B. Examine
C. Explore
D. Utilize
E. All of the above
Which of the following are NOT an agency approved abbreviation? (Hint: there are 2)
AKA
BioF
Cl
Clt
EHR
CG
SOC
YCC
Clt and CG
â–·Intervention: MHP utilized client centered approach and Trauma Focused Cognitive Behavioral Therapy to engage Cl in session to identify and process current life stressors and thoughts, feelings, and behaviors related to those stressors. MHP assessed for overall wellness/wellness practices.
â–·Response: Cl was not responsive to interventions by MHP AEB refusing to engage in session activities and made minimal eye contact. Cl presented to session upset when Adoptive Mom did not come into session. Cl finally came back with MHP, yet he refused to engage in session. MHP attempted multiple times to engage Cl in different activities, and he still refused. MHP attempted to assess for SI/HI/AVH/NSSI; however, Cl refused to engage or participate.
Wellness reponses.
Ms. May reported Cl has been acting out in class.
The use of a name. Use titles only.
Confidential information may be disclosed without consent when
Imminent risk of harm to self or others.
Suspected abuse or neglect of children, elders, or vulnerable adults.
Court order or subpoena (consult legal/clinical supervisor before release).
Serious safety concerns in emergencies.
What are the steps of SAFE-T?
Identify Risk Factors
Identify Protective Factors
Conduct Suicide Inquiry
Determine Risk Level
Document
Ask Bri to put the note back into draft.
Example: Therapist links Cl to community resource for psychological evaluation.
What should the therapist complete and document the next time they see the Cl and family?
Document follow up when linking Cl/family to resources.
Cl reported they were suicidal. MHP completed crisis plan. (HINT: 2 things are missing)
Missing SAFE-T documentation and detailed Cl Reponses about frequency, intensity, and duration.