Interim Inc.-Specific Documentation Standards

Transcription

1 Interim Inc.-Specific Documentation Standards 6/15/2015

2 Contents Bridge House Day Treatment... 2 Bridge House Residential... 3 Interim Manzanita House... 4 To write a needs appraisal... 4 For the weekly summary towards the needs appraisal:... 6 To Complete the Resident s Status Report to Psychiatrist... 6 For the Discharge Plan:... 7 Co-Signatures... 8 Crystal Reports... 8 Waitlist and Referrals... 9 Billing Codes... 9 Please refer to the Monterey County Behavioral Health Electronic Medical Record-AVATAR- {EMR User Guide} for full details on how to complete forms in AVATAR. Page 1

3 Interim-Specific Documentation Standards* Bridge House Day Treatment 1. Progress notes will be entered for clients in the program called Interim Bridge Day Treatment (63ASOCDT). Progress notes are entered using the service code 359 Day Treatment Group Non-Billable using the Progress notes (Group and Individual) form in Avatar a. Enter the number of minutes (duration) for the group. b. Service should be tied to the treatment plan. c. In the body of the progress note, indicate the start and end time for the client s participation in the group. Part 1 or 2 Part 2 or 2 Page 2

4 2. Individual Progress notes will be entered using service code 389 Daily Progress Note Non- Billable in the Clinical Progress Note MC form in Avatar. You may use this option to document staff s collaboration with family or other staff. a. Enter the number of minutes (duration) for the service. b. Service should be tied to the treatment plan. c. Once you have entered the information on the progress note click final. Bridge House Residential 1. Service should be documented in the program called Interim Bridge Residential (63ASOCRES) 2. Individual Progress notes will be entered using Clinical Progress Note MC form in Avatar. 3. Weekly Progress Notes should be entered with service code 399 Weekly Progress Note a. A duration of 0 minutes should be entered. b. Service should be tied to the treatment plan. c. Once you have entered the information on the progress note click final. Page 3

5 Interim Manzanita House 1. Services should be documented in the program called Interim Manzanita House (27ASOCMZ) 2. Progress notes will be entered using Clinical Progress Note MC form in Avatar. 3. Shift notes can be documented with the following service codes: a. 100 AM Shift Note Non Billable b. 101 PM shift Note Non Billable c. A duration of 0 minutes should be entered for all shift notes d. Once you have entered the information on the progress note click final. 4. Progress notes will be entered using Clinical Progress Note MC form in Avatar. 5. Weekly Progress Notes should be entered with service code 399 Weekly Progress Note a. A duration of 0 minutes should be entered. b. Once you have entered the information on the progress note click final. To write a needs appraisal 1. Individual Progress notes will be entered using Clinical Progress Note MC form in Avatar. 2. Enter the information in a progress note 3. Progress Notes should be entered with Service Code Save the note as co-signature required, send the note to be approved by the supervisor. Page 4

6 5. Right click and insert the template called Appraisal Needs Services Plan 6. Appraisal Needs Services Plan right click template will consist of: a. Assessment Date: b. Reassessment Date: c. Admission Date: d. Client Strengths: (Strengths that could assist with developing skills in the following areas.) e. Socialization: (Client s psycho-social skills, e.g. interpersonal relationship functioning.) i. Needs: Socialization/problem statement: f. Emotional: (Client s emotional functioning/emotional dysregulation, e.g. anger management, labile mood, etc.) i. Needs: Emotional/problem statement: g. Mental: (Client s psychiatric history, current mental health symptoms, and diagnosis/es) i. Needs: Mental/problem statement: h. Physical Health: (Client s medical needs, as reported, medical related diagnosis/es, allergies, and Restricted Health Conditions (RHC)) i. Needs: Physical /problem statement: i. Functioning Skills:(Client s educational, vocational, and other functional limitations such as meal planning, shopping, budgeting skills, and payeeship status.) i. Needs: Functioning /problem statement: j. Suicide Prevention: (Client s suicide/ self-harm history, including symptoms and current level of functioning.) i. Needs: Suicide Prevention/problem statement: 7. Fill in each section of the needs 8. Have the client sign the needs assessment before you finalize the note. If the client is not with you, save the note as a draft 9. After the needs are established; go into the treatment plan 10. Update the treatment plan with the needs identified in the needs appraisal. Page 5

7 For the weekly summary towards the needs appraisal: 1. Copy the most recent 103 Needs Appraisal note (we suggest you do this from the widget) 2. Past the assessment in the new progress note use the service code 399- Weekly Progress note 3. Under each heading; document the client s progress towards the need To Complete the Resident s Status Report to Psychiatrist 1. Use Clinical Progress Note MC form in Avatar to complete a progress note 2. Use 389 Daily Progress Note Non-Billable 3. Send the note Co-signature required for approval to the psychiatrist 4. Right click and use the template Resident s status report this template includes a. Delusional: b. Hyperactive: c. Hyperverbal/Pressured Speech: d. Using Medications as Prescribed: e. Appetite/Eating Problems: f. Substance Use: g. Sleep Disturbance: h. Aggressive Behaviors: i. Physical Health Problems: j. Depressed: Page 6

8 k. Self-harm behaviors: l. Other Psychiatric Symptoms or Issues: For the Discharge Plan: 1. Progress notes will be entered using Clinical Progress Note MC form in Avatar 2. Use service code 104 Discharge Note Non-Billable 3. Use the right click template Discharge Plan which consists of: a. Discharge Summary i. Discharge date: ii. Reason for discharge: iii. Describe circumstances of how client entered program iv. Describe treatment issues, Needs and Service plan goals, interventions and progress towards goals v. Additional treatment issues and how the client responded vi. Describe how the client left program vii. Follow up care b. Discharge Plan i. Discharge Living Environment & Independent Living Skills Evaluation ii. Day & Evening Structure: iii. Personal/ Social Supports iv. Wellness and Recovery Support System v. Money Management and budget vi. Food/Cooking Plan vii. Medication Management Plan viii. Mental Health Relapse Early Warning signs and Relapse Prevention Plan ix. Substance Use Relapse Early Warning signs and Relapse Prevention Plan x. Relapse Plan xi. Staff Recommendations c. Client to sign electronically d. Send note co-signature required to Supervisor for electron signature Page 7

9 Co-Signatures For Progress Notes that require a co-signature, be sure to select the co-signature required in the Note Type option. 1. Select the Co-Signature Required option 2. Selecting this option will send a to do message to the co-signing staff s To Do widget for review. 3. Once you have entered the information on the progress note click final. Crystal Reports 1. You may run report number 313 to see all services for a given service code. Page 8

10 Waitlist and Referrals This form should be used to receive referrals for entry to your program. Please refer to Chapter 20 of the EMR Guide for details on how to use this form. Billing Codes Bridge House Day Treatment Bridge House Residential Manzanita House 359 Day Treatment Group 399 Weekly Progress Note 100 AM Shift Note 389 Daily Progress Note 103 Needs Appraisal Note 101 PM Shift Note 399 Weekly Progress Note 104 Discharge Note 399 Weekly Progress Note 103 Needs Appraisal 104 Discharge Note Page 9

11 Other Functions: Function Avatar task Rules DC Summary Progress Note Rule: Signed by Client, staff, No Harm contract Scan into Interim folder in avatar signed by client and staff Safety Plan Scan to Safety Plan folder Handwritten and signed by client Assessment Interview form On paper *Once we are live on Avatar we will be more familiar with what info is available to us and can look at not keeping duplicate info. I can then look into making changes to our form, but we will need some time to do this. Interim agreements, policy, room searches etc. consent for rehab, consent for emergency medical services, consent for photograph, personal rights form Interim within consent form TB Test Healthcare plan Medication Record Status report Program fee agreement Sign out sheet Discharge Plan for client Will be scanned into appropriate interim folder. Scan this into the folder Scan in Interim folder Stays on paper, but scan in at discharge into the interim folder Stays on paper, but scan in at discharge Will be a template in the progress note, if the MD needs to know this, send the note Pending approval to the MD. Scan into interim folder Scan at discharge, into the interim folder Send discharge plan template to Amie this will be a progress note template in avatar Signed by client and staff Signed by client and staff Signed by client and staff Completed by clients and signed by staff Signed by client and staff Page 10