Documentation
Clients refusing to complete intake paperwork may result in this action.
WHAT IS "cancellation of the appointment"?
*Cancelled by admin.
How long is it expected for clients to be on bi-weekly frequency if they are moving towards successful termination?
WHAT IS 1 month?
If a client mentions any type of risk in their appointment, besides assessing for risk and completing 'risk assessment' thoroughly in TN note, what should be developed between client and clinician?
WHAT IS a safety plan?
*Clinician to email encrypted copy to client the day of and upload copy into TN.
Employees must use this prefix when calling clients to keep their personal numbers private.
WHAT IS *67?
This holiday was added to the observed holiday list for 2025.
WHAT IS Juneteenth?
What way is a discussion with a supervisor expected to be documented on TN?
WHAT IS a consultation note *only including necessary information?
-Outcome of consultation can be documented in consultation note and/or a progress note.
Whose responsibility is it to notify clients of Holiday closures and update the calendar to reflect such cancellations?
WHAT IS the Clinician/Therapist?
If a client refuses to voluntarily go to the ER for a psychiatric evaluation, this team must be contacted.
WHAT IS Law Enforcement or the Crisis Response Team?
Letters or documentation requests must be approved by this person before being sent.
WHO IS the director (Dr. Ivanna)?
This day, previously a paid day off, was removed in 2025 to avoid errors.
WHAT IS the employee's birthday?
When conducting an intake for a minor, the clinician will assess for the home life situation and it's impact on custody. When are custody documents expected to be emailed to clinicians to add to client's chart?
WHAT IS if the client's parent claims to have full custody?
What is the protocol for a client who cancels 2 or more sessions due to a vacation?
WHAT IS "call to confirm new appointment" upon returning?
After a CPS and/or APS report has been made to the appropriate authorities via phone call, what is the next step to take?
WHAT IS emailing Dr.Ivanna (encrypted) to print/file and email front admin staff (encrypted) so they can fax on clinician's behalf within 36 hours?
Why is emailing clients a form of communication we DO NOT encourage?
WHAT IS it creates liability for individual provider and leads to possible triangulation between client and office policies?
What must a clinician do if switching from zoom to phone in the middle of a session to ensure justification of billing?
WHAT IS document change in progress note and indicate why, so that zoom video session time matches.
How do you capture things such as trainings, creating zoom links and CPS/APS reports on TN?
WHAT IS creating "Scheduled Event" on TN otherwise known as, Admin Pay?
What happens if a clinician fails to cancel an appointment in advance when clients have canceled with clinician in a session?
WHAT IS PTO is deducted from clinician?
If completing a check-in with client and assessing for risk, what is the appropriate documentation expectation that follows? (i.e. contact note, consultation note, billable note, etc.)
WHAT IS a billable note? (Outlining interventions discussed to manage any symptoms and assessing for risk)
90832 (15-37 mins)
90834 (38 to 52 minutes)
To avoid double booking, what should clinicians do when a client has moved appointments?
WHAT IS notify the admin staff and Ivanna so they can remove the availability in Lucet?
What must a clinician do if an intake is added the same day and clients have not signed consents by their appointment time?
WHAT IS obtain verbal consent to conduct assessment and request they complete consents by the end of the week or their F/U appointment will be canceled?
*Please do not reach out to admin to verify documentation completion and/or cancel appointment on your behalf.
When is it appropriate to delete an appointment from the TherapyNotes calendar?
WHAT IS NEVER? - trick question ;)
*Do not delete any appointments that are cancellations and/or missed appointments- no matter who canceled the appointment. This is to ensure that communication is made to the admin, billing, and Dr. Ivanna.
When a clinician ends session early, they must take this action for any time remaining in the session.
WHAT IS log PTO for the time difference and add note in alert box outlining who ended early and why?
According to the Tarasoff ruling, this condition must exist for the duty to warn to apply?
WHAT IS a reasonably identifiable victim and foreseeable peril?
*AKA (serious threat of physical violence to a reasonably identifiable victim)
Name 2 examples of when it is appropriate to consult with an on-call supervisor?
WHAT IS:
-If client has indicated having risk more than ideation.
-If you are an associate and ANY risk presents itself during session.
-To consult on a Higher Level of Care.
-To discuss/explore personal hesitations, transference/countertransference when working with clients.
-Consultation on custody documents.
-To seek Legal and Ethical advice.
-To inquire about adding you as a therapist in TN.
What should a clinician do if a KP client shows up to complete intake but has not completed their TPI?
WHAT IS direct client to complete in that moment to allow you access to complete documents in Lucet?