CASE NOTES
PTC policy states that documentation should be completed within 24 hours of when service was provided. True or False?
What is True?
PTC policy 5.16-Clinical Documentation and Progress notes states that
Progress notes will be documented in the EHR within 24 hours of the contact with the patient
What is the form called you need to verify client's prescription from another provider?
Request for Information from Outside Medical Provider.
How many days is an initial treatment plan?
7 days.
What is the form called that clients fill out prior to intake?
Pre- Screening Form
30 days
DAP stands for.....
What is Data, Assessment & Plan?
What is the form called to request additional take home bottles?
Take Home 6 point evaluation.
How often are treatment plans updated?
Every 90 days or as clinically indicated.
What note needs to be completed day of intake by the counselor?
Intake Assessment
What 2 forms in methasoft does the counselor need to fill out when discharging a client?
1. External Facility Transition Plan
2. Discharge/Transfer
When conducting telehealth sessions, the counselor must document/ask what questions?
What is
1. Identifying factor of client, such as name, birthdate and/or client ID number
2. If client is in a safe and secure location for duration of session.
If client is traveling and needs additional take home bottles, what documents need to be filled out and/or uploaded?
1. Take home 6 point evaluation form
2. Documentation of trip , meaning plane ticket, hotel reservation, gas receipts.
What does SNAP stand for and where do you find them on the treatment plan?
Strength, Needs, Abilities & Preferences.
Top corner that looks like a notebook.
Before a client doses, what portal does the client need to be admitted into?
NJSAMS
When discharging a client, what document needs to be signed by supervision and uploaded into document manager?
NJSAMS Discharge
When conducting AWOL calls, which note do you use to document?
What is AWOL from Clinic note.
What is the form called should client's counseling requirements be reduced?
Return to Counseling Phase 1 Evaluation
Is there a limit to how many goals you can have for each dimension? If yes or no, state why.
No! For example for dimension 1, client may have ceased using opiates, however not cocaine. Clients can have MULTIPLE GOALS under each dimension.
What consent form do clients and doctor need to sign at intake?
Consent to Treat with Methadone or Consent to treat with Buprenorphine.
When a client is discharged, should we be cancelling their standing orders for transportation?
Yes. We want to cancel standing order for transportation to our facility so the client does not fall into non-compliance.
Name 3 out of the 7 items that a counselor should be reviewing when completing the case assignment clinical review note.
This counselor has reviewed the following items in the clinical record to familiarize his/herself with the patient's needs assessed, treatment goals, outcomes, services provided and services needed: 1.BPS/Interpretive Summary
2. ASAM(s)
3.Outcome Assessment Tools (GAD-7, PHQ-9, BAM, Columbia)
4.Treatment Plan(s)
5. H&P Nursing Assessment
6. Last medical/dose order
7. Last month's clinical note(s
External Facility Transition Plan: this form is done upon discharge. This forms reviews services that were provided throughout treatment as well as any EXTERNAL referrals made throughout treatment
Provide an example of a measurable method and measurable intervention pertaining to Dimension 5 (Relapse, Continued Use, Continued Problem)
COUNSELOR RESPONSE, JUDGE ON SITE
Name 3 out of the 5 patient assessments that need to be completed at intake.
1. Biopsychosocial
2. BAM-R
3. GAD -7
4. PHQ- 9
5. Columbia Suicide Severity Scale
After a client is discharge, what 2 assessments should we be completing 30 and 60 days after?
Discharge follow up 1 & 2.