NEO
it is important to track behaviors, mood, and affect in the progress note, why?
To be able to recognize and to take steps if a crisis is coming, being able to identify patterns
What are some ways of getting the right information?
1. Asking the other providers
2. Asking early on shift or during appointment
3. asking the client directly
There must be a link between what?
1.Treatment Plan
2. Interventions
3. Progress on the Progress Note
List 4 verbs be used in PSRI, CM, and Group training documentation?
•Brainstorm •Caution •Coach •Educate •Encourage •Explain •Familiarize •Foster •Inform •Inquire •Instruct •Model •Orient •Prepare •Prompt •Summarize •Role Play
When a client is enrolled in a High Risk Clinical Pathway, the Structured Follow up and Monitoring Steps will pop up to be completed for the outpatient episodes of care? True/False
TRUE
What information would you collect from a patient that would have indicators of suicidal ideation?
1. history
2. statements like "It's not going to matter much longer."
What is important to know about a potential triggers?
1. Triggers can be internal or external
2. That triggers are perceived
What are 5 reasons we document?
1. Justify billing
2. serves as a legal document
3. quality reviews
4. validates the patient care provided
5.impacts coding, billing and reimbursement
CCD is a clinical tool utilized for?
provides clients with the opportunity to provide their input and perspective on services and progress and allows clients and clinicians to clarify their understanding of important issues and focus on outcomes.
When documenting risk status, you are comparing the client’s risk to what?
Others in a similar situation or group
What is the most effective way to prevent someone from ending their life?
Limit access to lethal means.
Using inconsiderate and inaccurate terminology will aid with client's inclination to share? True/False
False.
"Sensitive and precise" will aid the client to share.
The Golden Thread is comprised of what 3 things?
1. Assessment and Reassessment
2. Treatment Plan/IRP
3. Progress Notes
List 2 verbs that can be used for IC, BHA, FC, and GC services.
•Analyze •Debrief •Explore
•Investigate •Normalize
•Process •Validate
Considering protective and risk factors are important when working with someone who may be experiencing suicidal ideation. Why?
More thoughtful planning for immediate, short term and long term goals.
What is meant by "suicidal intent"?
Clear desire and plan complete suicide
the want to unalive oneself
behaviors that could cause to die
What are some risk factors that may cause someone to be at a higher risk state or higher risk status?
1. Intoxication
2. Recent Loss
3. MH Diagnosis
4. Acute change in mental status
Suicide Risk Assessment is completed first, Why?
To determine if a crisis assessment is needed, to assess for SI
SNAPI is an acronym for what?
Strengths, Needs, Abilities, Preferences, and Interest.
When documenting risk state, you are comparing client’s risk to?
Client’s baseline or another significant time in their life
When assessing for risk of suicide, what question should you ask client?
"are you wanting to end your life?”
Name some protective factors that may support the client’s risk state or risk status.
coping techniques that work
belief system
someone who will assist with limiting access to lethal means
support network
The acronym SMART is what?
Specific, Measurable, Attainable, Realistic, and Time
3 things must be in place for a claim to be justified, what are they?
1.Valid Order
2. Treatment Plan
3. Authorization
The tool to create or review immediately when planning and responding is called what?
ABH Crisis Safety Plan or Safety Plan
or
Crisis Safety Plan