Documen-Tation Policies
When are notes due?
Any documentation should be completed within 24 hours of a service rendered.
When should an Integrated Service Plan (ISP) or Treatment Plan be updated?
Every 90 days or when clinically necessary.
What is a crisis?
A moment when a client feels unable to manage their emotions or cope with a situation.
After receiving notification that you have a new referral or transfer client, what is the first thing you should do?
Send the coordination of care email through ReliaTrax and add them to the caseload log.
Where should staff go to access agency resources, policies, procedures, and important updates?
The agency Intranet.
What are the different types of notes we complete?
DAP, Case Management, Contact, Staffing, CFT, Monthly Summary, (Discharge Summary & Plan if applicable)
When should a safety plan be completed?
It should be completed at intake and updated whenever risk changes or after a crisis or significant event.
True or False: A crisis only happens when someone is aggressive or physically unsafe.
False. A crisis can also present as withdrawal, self-harm, anxiety, sensory overload, or running away.
Name three documents that must be completed before a client’s intake appointment.
Why should staff maintain an updated caseload log?
To track assigned clients, monitor service needs, support organization, and ensure continuity of care.
-Complete Monthly Summary by last day of the month
-Send it out for clients who have an assigned case manager with a Behavior Health Home
-Complete a case management note of the outreach that is content based
What are the different types of screeners & when should they be updated?
ACES- Does not have to be updated after initial assessment
GAD-7 Every 90 days or as clinically necessary
PHQ-9 Every 90 days or as clinically necessary
CSSRS Whenever risk changes or after a crisis or significant event.
What is the primary goal of de-escalation techniques?
To calm the situation, prevent it from worsening, and help the client regain emotional control while maintaining their dignity and safety.
What should be reviewed before the first initial session?
Comprehensive Assessment, Integrated Service Plan (ISP), CALOCUS, Safety Plan, Referral Documents (if applicable)
Why are Relias trainings required for staff?
To ensure staff maintain required knowledge, competency, compliance with regulations, and agency expectations.
Name four characteristics of high-quality clinical documentation.
Accurate, timely, objective, complete, and supports medical necessity.
A Case Management Note is completed when staff provides care coordination or case management outreach services lasting 8 minutes or longer that support the client’s needs, treatment goals, resources, or continuity of care. Case Management Notes document the interaction, interventions provided, observations, and follow-up plans.
A Contact Note is used for non-billable communication or administrative/supportive interactions that do not meet criteria for a billable service, such as brief updates, coordination attempts, or other client-related contacts.
A client reports suicidal thoughts but denies a plan. What should staff do first?
Complete/review safety plan, notify the appropriate supervisor, and follow crisis protocol if deemed necessary (completing incident report, etc.)
What should you do during your first session with a client?
Introduce yourself to the client and parent/guardian (if youth client); check in with parent for the first 5 minutes
Review treatment plan
Review confidentiality policies
If you have a question about your daily clinical duties, client interventions, or a concern regarding a client’s treatment, who should you go to first?
Your direct team lead.
Why is documenting medical necessity important for AHCCCS reimbursement?
AHCCCS requires documentation demonstrating that services were medically necessary to support payment.
What is a CALOCUS and how often should it be updated?
A CALOCUS (Child and Adolescent Level of Care Utilization System) is a standardized assessment tool used to determine the appropriate level of care and service intensity needed for children and adolescents based on their behavioral health needs, functioning, risk factors, and support systems.
The CALOCUS should be updated every 6 months or when there is a significant change in the client’s clinical presentation, level of need, or treatment circumstances, and according to agency/AHCCCS requirements for reassessment.
Name two warning signs that may require immediate supervisor notification.
Suicidal statements, homicidal statements, abuse allegations, severe impairment, etc
How many missed appointments before a client is discharged and how long can a client be on hold?
After three missed appointments/no-shows, the client may be discharged for lack of engagement according to agency policy.
If services are placed on hold, the client may only be held for up to 30 days; however, their original appointment slot or placement is not guaranteed to be saved.
Bonus: “Who Do You Go To?” Round