TIFFE/CAMHD TIFFE/CAMHD Documentation TrainingDocumentation Training

GOALSGOALS

To ensure clinicians are adherent to To ensure clinicians are adherent to CAMHD/TIFFE documentation CAMHD/TIFFE documentation requirements (i.e., format, timeline, requirements (i.e., format, timeline, structure, etc).structure, etc).

To ensure clinicians produce/provide To ensure clinicians produce/provide quality of documentation (i.e., quality of documentation (i.e., individualized to each client/family, individualized to each client/family, S.M.A.R.T.). S.M.A.R.T.).

AGENDAAGENDA

Pre-testPre-test Required Intake Forms.Required Intake Forms. Mental Health Treatment Plan (MHTP).Mental Health Treatment Plan (MHTP). Progress NotesProgress Notes Monthly Treatment and Progress Monthly Treatment and Progress

Summary.Summary. Sentinel Events Report.Sentinel Events Report. Annual Summary Reports.Annual Summary Reports. Behavioral Plan.Behavioral Plan. Discharge Summary.Discharge Summary.

INTAKE FORMSINTAKE FORMS

Handout and Sample.Handout and Sample.

THE PURPOSES of MHTPTHE PURPOSES of MHTP

Contract agreement between Contract agreement between client and provider.client and provider.

Guide the course of treatment Guide the course of treatment for identified problems or issues.for identified problems or issues.

Evaluate the client’s progress in Evaluate the client’s progress in meeting specified goals and meeting specified goals and objectives. objectives.

Mean of communication Mean of communication between providers.between providers.

STEPS IN DEVELOPING MHTPSTEPS IN DEVELOPING MHTP

Gather information Gather information Review available information (reports, CSP, Review available information (reports, CSP,

medical records, court records, school records, medical records, court records, school records, etc.).etc.).

Interview process (youth, caregivers/guardians, Interview process (youth, caregivers/guardians, other provider/treatment team members, etc.).other provider/treatment team members, etc.).

Develop case formulationDevelop case formulation Identify clients’ current situations and what they Identify clients’ current situations and what they

want to accomplish.want to accomplish. Determine the most effective and appropriate Determine the most effective and appropriate

ways to help clients achieve their goals. ways to help clients achieve their goals. Identify possible barriers in accomplishing the Identify possible barriers in accomplishing the

goals.goals. Determine an estimated time to accomplish the Determine an estimated time to accomplish the

goals.goals.

REQUIRED COMPONENTS REQUIRED COMPONENTS OF MHTPOF MHTP Client’s DSM-TR IV diagnosis code(s) Client’s DSM-TR IV diagnosis code(s)

consistent with the assessment(s).consistent with the assessment(s). Goals and measurable objectives.Goals and measurable objectives. Target dates.Target dates. Appropriate strategies/interventions Appropriate strategies/interventions

(Best Practices).(Best Practices). A list of the services to be provided/who A list of the services to be provided/who

will provide the services.will provide the services. Crisis plan.Crisis plan. Transition/Discharge Plan.Transition/Discharge Plan.

REQUIRED COMPONENTS REQUIRED COMPONENTS OF MHTPOF MHTP Signature of client Signature of client (when appropriate).(when appropriate).

Signature of the client’s parents, Signature of the client’s parents, guardian, or legal custodian.guardian, or legal custodian.

Signature of the treatment team Signature of the treatment team members who participated in the members who participated in the development of the plan (at minimum development of the plan (at minimum MHCC).MHCC).

Date of start and end of services.Date of start and end of services.

MHTP MHTP Goal (WHAT))Goal (WHAT))

The end point of therapeutic work (Desired The end point of therapeutic work (Desired outcome). outcome).

Example of Goals:Example of Goals: Family = Develop positive family interaction.Family = Develop positive family interaction. School = Improve school/academic School = Improve school/academic

performance.performance. Community = Increase involvement in Community = Increase involvement in

community activity.community activity. Individual = Improve problem solving skills.Individual = Improve problem solving skills. Social/Peer = Develop and maintain positive Social/Peer = Develop and maintain positive

peer interactions.peer interactions. Legal = Maintain no involvement in law Legal = Maintain no involvement in law

violation.violation.

MHTPMHTP

Objective (HOW)Objective (HOW) Step(s) in achieving the goal.Step(s) in achieving the goal.

S pecificS pecific

M easurableM easurable

A ttainableA ttainable

R ealisticR ealistic

T ime-limitedT ime-limited

MTPS (Objective Examples)MTPS (Objective Examples)

DomainDomain GoalsGoals Measurable Measurable ObjectivesObjectives

IndividualIndividual Develop ability to Develop ability to communicate and communicate and verbalize feelings.verbalize feelings.

Joey will be able to identify Joey will be able to identify and label his feelings 90% of and label his feelings 90% of the time for a period of 3 the time for a period of 3 months.months.

Joey will be able to verbalize Joey will be able to verbalize his feelings to trusted his feelings to trusted adults/peers 75% of the time adults/peers 75% of the time for a period of 3 months.for a period of 3 months.

Joey will use an “I” statement Joey will use an “I” statement message to communicate his message to communicate his feelings to trusted feelings to trusted adults/peers 75% of the time adults/peers 75% of the time for a period of 3 months.for a period of 3 months.

MHTP MHTP (STRATEGIES/INTERVENTIONS(STRATEGIES/INTERVENTIONS

Based on best practice.Based on best practice. Need to consider youth’s Need to consider youth’s

diagnosis/issues.diagnosis/issues. Need to consider youth/family’s Need to consider youth/family’s

cultural in identifying appropriate cultural in identifying appropriate interventions.interventions.

Need to consider youth/family’s Need to consider youth/family’s resources or lack of resources.resources or lack of resources.

Need to consider youth/family Need to consider youth/family readiness for change.readiness for change.

REQUIRED COMPONENTS REQUIRED COMPONENTS OF MHTPOF MHTP Crisis Planning: Crisis Planning:

Address settings events, triggers, Address settings events, triggers, preventive as well as reactive intervention. preventive as well as reactive intervention. Must focus on early intervention.Must focus on early intervention.

Transition/Discharge Plan:Transition/Discharge Plan: Begin at the initial meeting.Begin at the initial meeting. Describe the supports and necessary services Describe the supports and necessary services

for successful and smooth transition.for successful and smooth transition. Identify the criteria for transition or discharged Identify the criteria for transition or discharged

based on MHTP goals and objectives.based on MHTP goals and objectives. Need to include contigency plan. Need to include contigency plan.

MHTP needs to be completed within 10 MHTP needs to be completed within 10 days of intake.days of intake.

CHARACTERISTICS of CHARACTERISTICS of GOOD MHTPGOOD MHTP Individualized to each client/family.Individualized to each client/family. Directly linked to achieving goals in a client’s IEP Directly linked to achieving goals in a client’s IEP

or/and CSP.or/and CSP. Identify client/family’s challenges as well as Identify client/family’s challenges as well as

strengths areas.strengths areas. Based on strengths, and needs driven.Based on strengths, and needs driven. Must be developed with youth (when appropriate) Must be developed with youth (when appropriate)

and parent/guardian involvement.and parent/guardian involvement. Written in client/family language.Written in client/family language. Problems/issues are stated using positive Problems/issues are stated using positive

language.language. Goals/objectives/interventions are appropriate to Goals/objectives/interventions are appropriate to

the client’s diagnosis, age, culture, strengths, the client’s diagnosis, age, culture, strengths, abilities, preferences, and needs expressed by the abilities, preferences, and needs expressed by the client/family.client/family.

Goals/objectives/interventions need to be Goals/objectives/interventions need to be attainable, realistic, measureable. attainable, realistic, measureable.

MHTPMHTP

GROUP ACTIVITYGROUP ACTIVITY

““Creating A Treatment Plan”Creating A Treatment Plan”

PROGRESS NOTESPROGRESS NOTES

PurposePurpose Serve as documentation of treatment.Serve as documentation of treatment. Track therapy progress. Track therapy progress. Essential part of therapy process.Essential part of therapy process. Ensure quality assurance.Ensure quality assurance.

Format (DAP)Format (DAP) D escription:D escription: A ssessment: This section is where you assess, A ssessment: This section is where you assess,

in descriptive terms, the client’s performance in descriptive terms, the client’s performance during the session and/or the session itself. during the session and/or the session itself.

P lan: The final section of your DAP notes is P lan: The final section of your DAP notes is where you outline the course of treatment, after where you outline the course of treatment, after considering the information you gathered during considering the information you gathered during the session. Next session date.the session. Next session date.

PROGRESS NOTESPROGRESS NOTES

Things to consider when writing Things to consider when writing progress notes:progress notes: Who are you writing your progress notes Who are you writing your progress notes

for? for? Yourself (clinician)Yourself (clinician) TIFFE (supervisor/program manager/clinical TIFFE (supervisor/program manager/clinical

director)director) CAMHD (care coordinator, auditor, QA CAMHD (care coordinator, auditor, QA

people)people)

Who will have access to your progress Who will have access to your progress notes?notes?

PROGRESS NOTESPROGRESS NOTES

Who will have access to your progress Who will have access to your progress notes?notes?

Agency (Supervisor, Clinical Director, etc.).Agency (Supervisor, Clinical Director, etc.). Client/CaregiverClient/Caregiver CAMHD (care coordinator, chief branch, CAMHD (care coordinator, chief branch,

CAMHD psychologist, etc)CAMHD psychologist, etc) Court system (probation officer, judge, etc.)Court system (probation officer, judge, etc.) Other agency/provider involves in client’s Other agency/provider involves in client’s

therapy (i.e., teacher, CPS, individual therapy (i.e., teacher, CPS, individual therapist, psychistrist, etc).therapist, psychistrist, etc).

Progress NotesProgress Notes

How much information need to be How much information need to be included?included?

Need to include adequate information in Need to include adequate information in regard what occur in therapy session related regard what occur in therapy session related to therapy goals/process.to therapy goals/process.

What are the issues being address?What are the issues being address? What are the goals being work on.?What are the goals being work on.? How do the issues or goals are being How do the issues or goals are being

address (specific strategies/intervention)?address (specific strategies/intervention)? How does youth response to intervention?How does youth response to intervention? What progress does youth make (describe What progress does youth make (describe

the progress)?the progress)? Is there any issues that might hinder the Is there any issues that might hinder the

youth’s progress?youth’s progress? How does this issue is being address?How does this issue is being address?

PROGRESS NOTESPROGRESS NOTES

What types of information need be What types of information need be included?included? Only include information, issues, or Only include information, issues, or

problems that have direct impact on problems that have direct impact on youth’s level functioning or directly youth’s level functioning or directly related to treatment.related to treatment.

PROGRESS NOTESPROGRESS NOTES

Who Relies On Your Documentation:Who Relies On Your Documentation: Treatment Team membersTreatment Team members Referral SourcesReferral Sources

To advocate for the most appropriate and To advocate for the most appropriate and effective care for client.effective care for client.

EmployersEmployers Other PayorsOther Payors

To justify need for continued treatment, need To justify need for continued treatment, need for admission, demonstrate appropriateness for admission, demonstrate appropriateness and cost-effectiveness of care, demonstrate and cost-effectiveness of care, demonstrate all billable services were provided.all billable services were provided.

PROGRESS NOTESPROGRESS NOTES

Samples of good progress Samples of good progress notes.notes.

Handouts.Handouts. Practice writing progress notes.Practice writing progress notes.

MONTHLY TREATMENT MONTHLY TREATMENT AND PROGRESS SUMMARYAND PROGRESS SUMMARY

SENTINEL EVENTS SENTINEL EVENTS REPORTSREPORTS PurposePurpose

To establish uniform guidelines for a reporting To establish uniform guidelines for a reporting system that is designed to track and document system that is designed to track and document sentinel events and the follow-up of the events sentinel events and the follow-up of the events reported by the CAMHD Branches and reported by the CAMHD Branches and contracted provider agencies (provider).contracted provider agencies (provider).

DefinitionsDefinitions Sentinel Event: An occurrence involving serious Sentinel Event: An occurrence involving serious

physical or psychological harm to anyone or the physical or psychological harm to anyone or the risk thereof, as defined under the categories of risk thereof, as defined under the categories of sentinel event codes and definitions. sentinel event codes and definitions.

Critical Event: Events involving serious injury or Critical Event: Events involving serious injury or death, suicidal attempts, sexual misconduct, death, suicidal attempts, sexual misconduct, allegations of staff abuse or misconduct. allegations of staff abuse or misconduct.

SENTINEL EVENTS SENTINEL EVENTS REPORTSREPORTS ProcedureProcedure

When a sentinel event occurs the When a sentinel event occurs the provider:provider:

Notify the youth’s legal guardian, and MHCC Notify the youth’s legal guardian, and MHCC within 24 hrs of the occurrence of the within 24 hrs of the occurrence of the sentinel event, either by phone of fax. sentinel event, either by phone of fax.

Complete CAMHD’s sentinel event report Complete CAMHD’s sentinel event report form (signed by TIFFE’s clinical director or form (signed by TIFFE’s clinical director or supervisor on site).supervisor on site).

Sentinel event report (signed by clinical Sentinel event report (signed by clinical director/supervisor on site) need to be faxed director/supervisor on site) need to be faxed to SES and MHCC within 72 hours of the to SES and MHCC within 72 hours of the sentinel event.sentinel event.

SUMMARY ANNUAL SUMMARY ANNUAL ASSESSMENTASSESSMENT Purpose:Purpose:

Address significant changes, current Address significant changes, current status and consequent status and consequent recommendation.recommendation.

Information to be included:Information to be included: Measures of youth’s behavior and Measures of youth’s behavior and

functioningfunctioning CAFAS/PECFAS CAFAS/PECFAS andand ASEBA checklist for ASEBA checklist for

parents, teacher and youth’s self report form parents, teacher and youth’s self report form need to be included.need to be included.

Structure/format (see handout).Structure/format (see handout). Write a progress notes indicating that Write a progress notes indicating that

you are working on Summary Annual you are working on Summary Annual Assessment (for billing purpose).Assessment (for billing purpose).

DISCHARGED SUMMARYDISCHARGED SUMMARY

Written discharge summary must be Written discharge summary must be submitted to appropriate CAMHD submitted to appropriate CAMHD Branches within ONE week of Branches within ONE week of service termination. service termination.

Post CAFAS/PECFAS needs to be Post CAFAS/PECFAS needs to be completed and turn in with your D/C completed and turn in with your D/C summary.summary.

CAFAS/PECFAS needs to include CAFAS/PECFAS needs to include pre/post score on individual as well pre/post score on individual as well as family functioning. as family functioning.

D/C date is the last session you had D/C date is the last session you had with youth/family. with youth/family.

SENTINEL EVENT REPORTSENTINEL EVENT REPORT

Sentinel events Handouts.Sentinel events Handouts. Sample.Sample.

ClosingClosing

Q & A Q & A Post-testPost-test EvaluationEvaluation