Administrative
What are the primary sources of information we need to complete a "prospective patient" entry for all new referrals?
Name
DOB
Address
Contact Information
Insurance
How often does a CANS Assessment need to be completed on the VG?
Admission then every 6 months.
In addition to the NP Eval (assessment) what else should be completed as part of the initial intake appointment?
Dr. First: Medication List, Allergies
Review clinic practices and procedures with medication services
Consents for medication (if applicable)
What are the 2 first steps in scheduling the patient for annual evaluation?
Send new forms packet to portal
Send any measures needed
What are the 3 main types of discharges?
Successful
Voluntarily
Involuntary
When a prospective patient is made "active" what are the 2 next important items to complete in their profile?
Portal
Program Assignment
Assigned Provider
What is the purpose of the "intake" with a provider versus the administrative intake? - Date of Assessment is admission to program
Explain therapeutic process/relationship
Collect background information to complete assessment (biopsychosocial)
Where does the provider for medication services need to indicate their treatment plan?
At the end of every encounter note
After completing a new intake (assessment) what 2 things need to be updated from that assessment?
Treatment Plan
Diagnosis
2 cancelled in 30-day period removed from provider's schedule and put on a waiting list
No Show: each should have a documented call log attempts to the patient. After 2 unsuccessful calls from a no-show patients are removed from provider's schedule and put on WL.
After 30-days of no contact a patient can be discharged from program.
Before a patient is seen by a provider what needs to be completed
Intake forms - no consent to treatment means no treatment should be provided
What items require selecting the supervisor for signature?
Assessment
Treatment Plan
Discharge Plan
How often does an NP Eval and treatment plan need to be updated?
Every year or as clinically indicated.
DOUBLE Points Bonus: five an example of clinically indicated need
Patients who report a SI history or current SI/SIB what should be completed?
CSSRS & anyone scoring as moderate to high risk - a safety plan
What are the steps to completing a discharge?
1) Complete discharge/transition mobile note in patient chart (with/without patient)
2) Send appropriate PT Letter for those that did not participate in discharge planning (no-contact 30+ days, multiple no-shows/cancellations)
3) Make profile inactive with discharge reason applied to "custom" tab
How do you distinguish between what goes in the clinical record and what goes into the patient profile?
Profile - "about the person"
Chart - "about the care"
How soon after an assessment is completed should the treatment plan be signed by the patient and clinician
within 30 days of intake admission
How often does someone need to be seen in person for medication services
1st visit (NP Eval)
Every 3 Months if seen via telehealth primarily
Preferred all annual NP Evals - can make exceptions with provider/CD approval
For new patients in therapy how often should you schedule them for sessions (considered relationship building)
What is the appeal process for involuntary terminations?
Written statement with patient contact information to the ED for follow up.
How often should records be updated and reviewed?
Every time something occurs/daily. Keep records as "fresh" as possible for compliance, audits, and good patient care coordination.
Look out for and respond to appointment notes/alerts to help everyone out!
How often are you supposed to update an assessment & treatment plan
Every year - or if clinically indicated/Warranted.
DOUBLE POINTS: give an example of clinically indicated
What are 2 additional treatment planning tools used in the care of patients on psychiatric or SUD controlled substances?
PMP
Urine Screens
What are the 3 tiers of documentation
Golden standard - at time of visit with patient
Silver - 24-48 hours after visit
Bronze - by end of week from the visit
How often should active clients be reviewed for appropriate discharge coordination?
Often - it is the responsibility of provider staff to keep on top of patient's treatment course and determine who needs outreach vs discharge.