Assessment
Can you bill for reviewing an assessment and/ or completing assessment documentation same day?
Yes
Whose responsibility is it that we have consents in the chart?
The clinician
The number you put under social security if we do not have one on file and/ or client does not have one?
9999
How long should a safety related goal be sustained for?
2 months/ 8 weeks
This is when you complete a safety plan.
As soon as you find out about safety concerns (same day) i.e. self-harm, self-harm ideation, suicidal ideation, passive suicidal ideation, physical aggression, AWOL'ing, property destruction, animal abuse, homicidal ideation, pyromania, eating concerns (starving/binging/purging), and hallucinations/delusions
What do you do when you see a referral in the assessment?
Support the family in getting connected to that referral and document.
Parents have never been married and no custody paperwork is in place. Who can consent for services?
Either parent. However, best practice is to get custody from both parents.
The differences between an AMR and ROI.
-AMR is to release records as requested.
- PHI is to communicate with outside entities regarding client's mental health and/or to schedule appointments.
How long should a regular goal be sustained for?
4 weeks
Name 5 proactive interventions.
Deep breathing, grounding techniques, going to safe space, talking to a trusted person, listening to music, taking a walk, watching a favorite show/movie, for SATS cases calling on-call clinician, calling/texting 988 or some other crisis hotline, contacting caregiver, etc.
This must be completed at every assessment.
Risk assessment
When do you complete a caregiver affidavit?
- When no custody agreement is in place and 1 parent is unable to be contacted.
- When no guardianship is in place and neither parent is reachable.
Who can obtain an ROI/ AMR?
Anyone can get ROI/ AMR signed :)
Client driven treatment goals must be the following:
Behavioral, measurable, and relevant to the client's functional impairment.
Name 3 reactive interventions.
Calling 911, taking client to emergency room, calling Community Crisis Response Team(CCRT), taking client to Crisis Stabilization Center (CSU)
The presenting problem should include?
-Demographic information about the client including their age, race/ethnicity, gender, and referral information.
-Client’s presenting mental health problem, which includes past symptoms, current symptoms and behavior(s).
-Include a description of the onset of the presenting problem, its duration and intensity and describe the impairments/ distress it causes in client’s daily functioning.
Name 5 things included in the consent packet.
-Consent for Outpatient Treatment
-Acknowledgement of Receipt of NOPP
-Acknowledgement of Receipt of Medi-cal Booklet
-Authorization to Release PHI
-Appointment Agreement
-Program Participation Agreement
-Authorization to Transport
-Consent for A/V Recordings and Observations
-Advanced Directive Notice
Name 4 entities in which NO ROI is needed for the purpose of coordinating health care services and medical treatment, mental health services, or services for developmental disabilities, for the minor and HIPAA Minimal Disclosure Rule may or may not apply.
-County Social Worker
-Probation Officer
-Foster Parent
-Other Person legally authorized to have custody or care of the child
-Attorney appointed by court for child
-Qualified caregiver
-Healthcare provider
How does one develop a treatment goal?
-Collaborate with client to identify the diagnosis that is causing the most severe impairment.
-Identify at least 2-3 primary concerns that are related to the diagnosis.
-Think about the actual action that is a result of the symptom. These actions must be observable and measurable.
-Create the goal label (must be behaviorally stated).
-Identify appropriate baseline for goal.
-Goal should only consist of measurable, observable, and behavioral qualities.
What are the different types of risk level and their meaning?
-Low risk: Thoughts of death, no plan, intent or behavior
-Moderate risk: Suicidal ideation with plan, but no intent or behavior
-High risk: Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal
How is medical necessity determined at assessment?
-The person has significant impairment in social, occupational, or other important life activities and/or there is reasonable probability of significant deterioration in important area of life functioning
-AND the significant impairments listed above are due to a mental health disorder, Diagnostic Statistical Manual, Fifth Edition (DSM-5), either diagnosed or suspected, but not yet diagnosed.
Name 3 types of legal custody documentation that are required to be scanned into the chart.
-Adoption Orders
-Custody Orders (in cases of divorce)
-Legal Guardianship orders
-CFS court reports showing dependent of court
-Caregiver Affidavit
How long do we have to release records when an AMR is completed?
5 days if requesting to inspect records.
10 days for summary report/letter.
15 calendar days for entire chart.
What happens after a client has achieved their treatment goals?
-Collaborate with client to discuss reaching their treatment goals.
-Identify any other primary concerns that are related to the diagnosis.
-If no other primary concerns exist, begin termination process.
What are the 5 steps you take to assess for risk?
-Identify risk factors
-Identify protective factors
-Conduct suicide inquiry (or link client with someone who can) to assess for suicidal thoughts, plans, behaviors, and intent.
-Determine risk level/ intervention
-Document