General
How many Z codes should you use
1-3
why is it important to write professionally as possible?
Legal medical record
other professional read documentation
Client could read documentation
when do you document as CMC
one on one with client face to face
what textbox sections need to be filled out on every note
Reason for visit
intervention
response
plan
How can you capture a clients frustration
focusing on the observable facts
using Appeared and as evidenced by
When do you code as CMO
Anytime more than one service provider is present ( eternal or external) or other non family individuals.
General rule of thumb for CMC encounter
8 mins
before you finalize your document you should always
double check your work
ensure readability and fix errors
what is difference between CMT and telephone note
CMT is providing valuable services over the phone
(using case management skills)
Telephone note: leaving messages, brief communications, emails,
Your assessment diagnosis (Z- code) should relate to
intervention what you did specifically in that visit.
difference between single and double quotes
' ' v " "
single quotes paraphrasing capturing the idea
double quotes client specifically stated it
CM outreach no contact and wants credit for the time
how do you document
Chart update
Case managers should never use this code only Peers should
PSS- Peer support with client.
What is the golden thread
•The consistent presentation of relevant clinical information throughout all documentation for a client
•Tying the record together
•Documents flow logically from one note to the next
When coding as a CMO always make note of who
is present at the encounter. ensures comprehension for other readers.