IMA
1. Full electronic health record under Demographics
2. Lookup > Client Lookup
30 Min session, held in person, with 29 year old client.
R30
How often should clients be scheduled for therapy sessions?
Once per week.
13 year old client got into a physical altercation with sibling.
Not reportable.
When should progress notes be completed?
No later than 24-48 hours after the date of service.
Find the suicide risk assessment
CSSRS - located in EHR > Assessments/Forms
45 minute video session, held with 13 year old client.
V45
What is the minimum requirement for collateral participation in sessions?
At least one collateral session a month.
Client takes 2 tylenol because she "wanted to just sleep and not be here."
Reportable as a suicide attempt.
What are the primary IMA write templates therapists use?
Individual, collateral, family, case management, and no show.
What is on the To Do list
- Scheduling
- Caseload
- Clients Not Seen
- Progress Notes
Video Admission session is also known as ...
VAM
After a missed session, what steps should be taken?
Outreach to the client, leave a message, send a missed session letter
Client reports suicidal ideation, with plan to ingest pills over the weekend.
Not reportable, however, a referral to the hospital for further evaluation and possible admission would be warranted.
What is the best practice for documentation and time management?
Concurrent Documentation
How do you add a collateral to the system?
Client registration/services/schedule > Client collaterals > Add
Collateral participates in 5 minutes of the video session, the remaining 25 min of the session are held with the 5 year old client.
V30 with note indicating that the collateral participated in part of the session.
What is the easiest way to ensure that clients are scheduled consistently?
Schedule the client's next appointment at the end of each session.
12 year old client discloses that she's been cutting her arm, wrists and legs with razors.
Not reportable, but collaborate with collateral, update the safety plan and consider possible referral to psych ER.
What are some ways to keep track of progress notes due?
Check the IMA To Do List
Review NYPCC Reports for Progress Notes
How do you access a client's treatment plan?
IMA homepage > Electronic health record > treatment plans
Session started, however, gets disconnected after 10 minutes and therapist is unable to make contact with client.
Not a billable activity code, should be a case management note.
Show us how to schedule recurrent appointments.
Calendar > Copy > Add member > Include all dates > Copy
15 year old client runs away from NYPCC clinic after therapy session with you.
Reportable because it happened on site.
If you do not check in your client, you can not _____.
Write the progress note.