Documentation and Records
The compliance time limit for completing progress notes shares a name with this 2008 Matisyahu song.
What is "One Day"?
This "minor detail" should always be included in methods for clients under 18.
What are phone/Zoom collateral sessions?
Switching from V45 to A45 may mean you need to manually include this section.
What is the audio-only declaration?
Using ELEOS regularly will not make our job easier or save us valuable time as therapists. It is not a way to allow us to train more, see more clients, or just chill more.
False. It can actually do all those things. Quite efficiently, too.
This important note type shares a name with a Carl Sagan book written in 1985. It must be entered for ALL interactions with clients between sessions.
What is a contact note?
It is problematic not to personalize this TP section with the specific presentation of a client's symptoms.
What is the "problem" section?
Justification for audio sessions must be "dually noted" in these two documents.
What are progress notes AND treatment plans?
"I'm having a 'good face for radio' day" is a good justification for a therapist to request an audio session.
False. Radios don't have faces.
Also, audio sessions have to be by client's request.
Access to ANY client records or personal health information is only allowable under these conditions.
What is a "need to know" basis?
The 6-month treatment plan due date refers to the signature of this individual. The other signature is due two weeks before.
What is a psychiatric provider?
"Where the client is at" can refer to a client's readiness for change or this important telehealth documentation detail.
What is "client's location"?
Relias trainings are valuable for helping clinicians stay in compliance and up to date in their clinical knowledge.
True! These trainings are both valuable and important. They contribute to solid performance as an employee.
This phrase suggest that therapists have the ability to control reality through documentation.
Having this kind of session regularly must be clinically justified in the treatment plan.
What is a very short session?
This must be shown and documented in every telehealth session even if you know the client personally.
What are two forms of identification?
It's best practice to double-check the latest available diagnosis from the psychiatric provider before signing off on a treatment plan.
True! Keeping things consistent across the case helps inform treatment.
This evaluation shares a name with a 24-note bugle call written by Brigadier General Daniel Butterfield and may suggest follow-up evaluations that need to be done.
What is TAPS?
A client reports on intake that she will not be able to have in-person or Zoom sessions regularly, as she lives in a submarine in the Hudson River. Her submarine has no WiFi. Her preference needs to be recorded in this treatment plan section.
What is the "Service Delivery" section?
This is the most commonly used phrase in telehealth sessions.
What is "Can you hear me?"?
Clients must be seen within a specific time frame following a psych/SUD hospital discharge.
True! We have 7 days to see a client coming out of this situation.