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Clinical Notation: Documentation for clients in treatment - CASAT

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CLINICAL NOTATION:DOCUMENTATION FORCLIENTS IN TREATMENTApril 5, 2011Presenters: Steve McLaughl<strong>in</strong> & Roberta Miranda


Our Personal Goal…Help cl<strong>in</strong>icians keep cl<strong>in</strong>ical documentationclient-drivenHelp agencies develop consistency withdocumentationHelp with develop<strong>in</strong>g a solid understand<strong>in</strong>g ofthe <strong>treatment</strong> episodeTo learn how <strong>clients</strong> can be experts, will helpguide <strong>treatment</strong>Help alleviate apprehension regard<strong>in</strong>g thewrit<strong>in</strong>g of cl<strong>in</strong>ical notations


IntroductionsSteve McLaughl<strong>in</strong>, M.S., LADCRoberta Miranda, M.S., LADCIntroduction from AttendeesWhat is someth<strong>in</strong>g you hope to cover <strong>in</strong>today‟s tra<strong>in</strong><strong>in</strong>g?


Outl<strong>in</strong>e For <strong>Cl<strong>in</strong>ical</strong> <strong>Notation</strong>• Client In<strong>for</strong>mation gathered dur<strong>in</strong>g assessment• Progress Notes• What to do• What not to do• What should be <strong>in</strong>cluded?• Alignment with <strong>treatment</strong> plan• Treatment Plann<strong>in</strong>g• Discharge• Electronic <strong>Notation</strong> (NHIPPS)Four Modules of approximately 1 hr/each


Interactive Dialogue!


Electrical <strong>Notation</strong>One goal of this tra<strong>in</strong><strong>in</strong>g is to enhanceproficiency and consistency with electronicdocumentation systemsSpecifically, to answer common questions thatcan help with NHIPPS efficiency(Examples will be taken from theNHIPPS system)


What is NHIPPS?The Nevada Health In<strong>for</strong>mation Provider Per<strong>for</strong>mance System(NHIPPS) is a web-based management system and cl<strong>in</strong>icaltool that uses the <strong>in</strong>dustry standard ASI-Lite assessment tool<strong>for</strong> client assessment and evaluation.NHIPPS allows providers to track client progress andoutcomes and SAPTA to submit Nevada‟s NOMs data toSAMHSA.NHIPPS allows the provider agency or SAPTA staff to generateonl<strong>in</strong>e reports and export the data to standard Microsoftproducts <strong>for</strong> further analysis.Data are entered <strong>in</strong>to NHIPPS by every state-funded substanceabuse <strong>treatment</strong> agency <strong>in</strong> Nevada. In order to ma<strong>in</strong>ta<strong>in</strong> theSAPTA fund<strong>in</strong>g grants <strong>for</strong> their organizations, all of theproviders of substance abuse prevention and <strong>treatment</strong>submit data through a secure web-based <strong>in</strong>terface.


Who is SAPTA?The mission of the Substance Abuse Prevention and TreatmentAgency (SAPTA) is to reduce the impact of substance abuse <strong>in</strong>Nevada.Objectives:• Statewide <strong>for</strong>mulation and implementation of a state plan <strong>for</strong>prevention, <strong>in</strong>tervention, <strong>treatment</strong>, and recovery ofsubstance abuse.• Statewide coord<strong>in</strong>ation and implementation of state andfederal fund<strong>in</strong>g <strong>for</strong> alcohol and drug abuse programs.• Statewide development and publication of standards <strong>for</strong>certification and the authority to certify <strong>treatment</strong> levels ofcare and prevention programs.


SAPTA Accomplishments:• SAPTA serves as the S<strong>in</strong>gle State Authority (SSA)<strong>for</strong> the federal Substance Abuse Prevention andTreatment (SAPT) Block Grant provid<strong>in</strong>gsubstance abuse prevention or <strong>treatment</strong> servicesvia a competitive process to non-profit serviceproviders and governmental organizations.• In state fiscal year 2010, the SAPTA budgettotaled nearly $26.8 million, <strong>in</strong>clud<strong>in</strong>gapproximately $16.4 million <strong>in</strong> federal supportand approximately $10.4 million <strong>in</strong> state funds.


Module 1• Review of a TreatmentEpisode• Screen<strong>in</strong>g & Assessment• Review of M.I.• Stages of Change• ASAM


What‟s <strong>in</strong> a Treatment Episode?Screen<strong>in</strong>gAssessment/Wait ListASAMAdmissionProgress NoteTreatment PlanAdd Review/Monthly ASAMDischarge/Aftercare Plan


IntroductionTen NOMs Doma<strong>in</strong>s• Reduced symptomatology from mental illnesses or abst<strong>in</strong>encefrom drug use and alcohol abuse• Gett<strong>in</strong>g and keep<strong>in</strong>g a job or enroll<strong>in</strong>g and stay<strong>in</strong>g <strong>in</strong> school• Decreas<strong>in</strong>g <strong>in</strong>volvement with the crim<strong>in</strong>al justice system• F<strong>in</strong>d<strong>in</strong>g safe and stable hous<strong>in</strong>g• Improv<strong>in</strong>g social connectedness to others <strong>in</strong> the community• Increased access to services• Retention <strong>in</strong> substance abuse <strong>treatment</strong> or decreased<strong>in</strong>patient hospitalizations <strong>for</strong> mental health <strong>treatment</strong>• Client perception of care• Cost-effectiveness• Use of evidence-based <strong>treatment</strong> practices


NOMS• How do cl<strong>in</strong>icians collect the NOMs data?• Generally, authorized system users log <strong>in</strong>to NHIPPS andenter the client data directly. In case of a system outage,SAPTA does provide paper-based <strong>for</strong>ms that match allscreens that system users complete <strong>in</strong> the system. Usuallycl<strong>in</strong>ical staff enter all of the <strong>in</strong><strong>for</strong>mation associated with the<strong>treatment</strong> life cycle <strong>in</strong>clud<strong>in</strong>g:• Substance and Gambl<strong>in</strong>g Screen<strong>in</strong>g <strong>in</strong><strong>for</strong>mation• The ASI-Lite Assessment <strong>in</strong><strong>for</strong>mation• Division Placement Criteria (DPC)• Admission and Discharge Data• Treatment plans, progress notes, and <strong>treatment</strong> plan reviews• Waitlist and <strong>in</strong>terim services track<strong>in</strong>g <strong>in</strong><strong>for</strong>mation


Screen<strong>in</strong>g vs. Assessment• Screen<strong>in</strong>g is a process <strong>for</strong> evaluat<strong>in</strong>g thepossible presence of a particular problem.• Assessment is a process <strong>for</strong> def<strong>in</strong><strong>in</strong>g the natureof that problem and develop<strong>in</strong>g specific<strong>treatment</strong> recommendations <strong>for</strong> address<strong>in</strong>gthe problem.


Screen<strong>in</strong>g• Screen<strong>in</strong>g is a <strong>for</strong>mal process of test<strong>in</strong>g todeterm<strong>in</strong>e whether a client does or does notwarrant further attention at the current time <strong>in</strong>regard to a particular disorder• A screen<strong>in</strong>g process can be designed so that itcan be conducted by counselors us<strong>in</strong>g theirbasic counsel<strong>in</strong>g skills• There are seldom any legal or professionalrestra<strong>in</strong>ts on who can be tra<strong>in</strong>ed to conduct ascreen<strong>in</strong>g.


Assessment• A basic assessment consists of gather<strong>in</strong>g key <strong>in</strong><strong>for</strong>mation andengag<strong>in</strong>g <strong>in</strong> a process with the client that enables the counselor tounderstand the client's read<strong>in</strong>ess <strong>for</strong> change, problem areas, CODdiagnosis(es), disabilities, and strengths. Intake <strong>in</strong><strong>for</strong>mation oftenconsists of• Background—family, trauma history, history of domestic violence(either as a batterer or as a battered person), marital status, legal<strong>in</strong>volvement and f<strong>in</strong>ancial situation, health, education, hous<strong>in</strong>gstatus, strengths and resources, and employment• Substance use—age of first use, primary drugs used (<strong>in</strong>clud<strong>in</strong>galcohol, patterns of drug use, and <strong>treatment</strong> episodes), and familyhistory of substance use problems• Mental health problems—family history of mental health problems,client history of mental health problems <strong>in</strong>clud<strong>in</strong>g diagnosis,hospitalization and other <strong>treatment</strong>, current symptoms and mentalstatus, medications, and medication adherence


Assessment-ASI Lite/NHIPPSThe assessment is broken <strong>in</strong>to ten sections, most of which correspond to thesections <strong>in</strong> the ASI-Lite. The fields <strong>in</strong> these sections match the questionspresented <strong>in</strong> the ASI-Lite. The sections are listed below (the sectionsmarked with an asterisk are on the ASI-Lite):• General *• Medical *• Employment/Education *• Substance *• Legal *• Family *• Psychiatric (Mental health) *• Diagnostic• Cl<strong>in</strong>ician


Twelve Steps <strong>in</strong> the AssessmentProcess (TIP 42):Step 1: Engage the clientStep 2: Identify and contact collaterals (family, friends, otherproviders) to gather additional <strong>in</strong><strong>for</strong>mationStep 3: Screen <strong>for</strong> and detect CODStep 4: Determ<strong>in</strong>e quadrant and locus of responsibilityStep 5: Determ<strong>in</strong>e level of careStep 6: Determ<strong>in</strong>e diagnosisStep 7: Determ<strong>in</strong>e disability and functional impairmentStep 8: Identify strengths and supportsStep 9: Identify cultural and l<strong>in</strong>guistic needs and supportsStep 10: Identify problem doma<strong>in</strong>sStep 11: Determ<strong>in</strong>e stage of changeStep 12: Plan <strong>treatment</strong>


DSM-IV-TR Justification


DSM-IV Diagnos<strong>in</strong>gDSM-IV diagnosis must be justified and detailedIf there is a rule/out-monitor throughout txepisodeUtilize V-codes when warranted


Scopes of PracticeRemember to Adhere to Regulations of theLicens<strong>in</strong>g boards regard<strong>in</strong>g scopes ofpracticeRefer, if necessaryIf LADC/CADC/CADC <strong>in</strong>tern-can addressitems related to substance use


Previous DiagnosisBe m<strong>in</strong>dful of co-occurr<strong>in</strong>g issuesConsider impact of substance use (activeuse or withdrawal symptoms could mimicmental health disorders)Ask specifics of any previous mental healthdx (document when, who, where) andsuggest consents to contact previousproviders


Previous Dx, cont…Diagnose with the least restrictive dx (onecan r/o a Dependence dx)Do not change a Dependence dx back to anAbuse dx (despite length of abst<strong>in</strong>ence)Include dx specifiers (ex: “304.30 CannabisDependence, Early Full Remission-<strong>in</strong> acontrolled environment”)


Comprehensive Evaluations• With<strong>in</strong> scope of practice of assess<strong>in</strong>g cl<strong>in</strong>ician• Include the diagnoses, justification of dx, andv-codes (if applicable)• Keep <strong>in</strong> m<strong>in</strong>d, identified areas of concern(medical, family, mental health, substance use,employment, etc.) need to be reflected <strong>in</strong> theASAM/HDPC summary and <strong>treatment</strong> plan


Recommendations <strong>for</strong> TxThe screen<strong>in</strong>g and assessments havebeen completed…now what???


ASAM PPC-2RThe American Society of Addiction Medic<strong>in</strong>e's(ASAM) Patient Placement Criteria (ASAM PPC-2R) is the most widely used and comprehensivenational guidel<strong>in</strong>es <strong>for</strong> placement, cont<strong>in</strong>ued stayand discharge of patients with alcohol and otherdrug problems.The ASAM PPC-2R provides two sets of guidel<strong>in</strong>es,one <strong>for</strong> adults and one <strong>for</strong> adolescents, and fivebroad levels of care <strong>for</strong> each group. With<strong>in</strong> thesebroad levels of service is a range of specific levelsof care.


ASAM/DPC (Placement Criteria)Justification <strong>for</strong> level of care.Dimension 1: Acute Intoxication/Withdrawal PotentialDimension 2: Biomedical Conditions and ComplicationsDimension 3: Emotional/Behavioral/Cognitive Conditions andComplicationsDimension 4: Read<strong>in</strong>ess to ChangeDimension 5: Relapse/Cont<strong>in</strong>ued Use/Cont<strong>in</strong>ued Problem PotentialDimension 6: Recovery EnvironmentASAM Criteria should be utilized to:1. Assign the appropriate level of service and level of care2. Do effective <strong>treatment</strong> plann<strong>in</strong>g and documentation3. Make decisions about cont<strong>in</strong>ued service or discharge by ongo<strong>in</strong>gassessment and review of progress notes


ASAMWhat is the ASAM not?• The equivalent of the DSM-IV• A substitute <strong>for</strong> cl<strong>in</strong>ical judgment• A checklist or cookbook• A replacement <strong>for</strong> the ASI


ASAM/HDPCASAM drives <strong>treatment</strong>!InitialASAMUpdatedASAMFirst txplangoalsTx planupdates30 dateASAMupdate


ASAM &Treatment Levels Crosswalk• Level 0.5 Intervention• Level I Outpatient• Level II.1 Intensive Outpatient• Level II.5 Day/Night Treatment• Level III.1 Level IV Residential• Level III.3 Level III Residential• Level III.5 Level I & II Residential• Level I-D Detoxification


Justify your Recommendation!Remember:Support your recommendation <strong>for</strong> level ofcare/<strong>treatment</strong> with driv<strong>in</strong>g dimensions <strong>in</strong> yourassessment summary!Ex: “Based on driv<strong>in</strong>g dimensions 3 and 5, and DSM-IV diagnosis of 305.20 Cannabis Abuse, John isrecommended <strong>for</strong> Level 1.0 Outpatient counsel<strong>in</strong>g atthis time. He is recommended <strong>for</strong> one <strong>in</strong>dividualsession and two outpatient group sessions per week.To be reviewed <strong>in</strong> 30 days.”


Transferr<strong>in</strong>g to a Different Levelof CareHow does your agencydocument a change <strong>in</strong> level ofcare?


Prochaska & DiClementeThe Stages of Change, part of theTranstheoretical Model of Change, depicts thisprocess that people go through when theysuccessfully make changes <strong>in</strong> their lives.Because it is a model of how people change<strong>in</strong>stead of a theory of psychopathology, it allowcounselors widely differ<strong>in</strong>g theory.


Stages of Change…


Stages of ChangePrecontemplationContemplationPreparationActionMa<strong>in</strong>tenanceRecurrence


Stages of ChangeKey Po<strong>in</strong>ts:Stages of Change are Fluid-can move back and <strong>for</strong>thCan be used <strong>in</strong> our “<strong>Cl<strong>in</strong>ical</strong> Communication”Helps us to evaluate where <strong>clients</strong> are <strong>in</strong> theirprocessIs not <strong>in</strong>dicative of how “well” the cl<strong>in</strong>ician is do<strong>in</strong>gIs encouraged <strong>in</strong> <strong>treatment</strong> plans and cl<strong>in</strong>icaldocumentation (addresses progress)Can be addressed <strong>in</strong> progress notes and dimension 4


Challenges dur<strong>in</strong>g AssessmentWhat if my client does not want to answerquestions dur<strong>in</strong>g the assessment process?


Understand<strong>in</strong>g Resistance“…the least desirable situation, from thestandpo<strong>in</strong>t of evok<strong>in</strong>g change, is <strong>for</strong> thecounselor to advocate <strong>for</strong> change while theclient argues aga<strong>in</strong>st it.”(Miller & Rollnick, 2002, page 39)Add pressure and you will surely <strong>in</strong>creaseresistance. Remove pressure and if the clientfeels free to move, resistance will oftendecrease.


Understand<strong>in</strong>g ResistanceArises from the <strong>in</strong>teraction betweenclient and practitionerIs normal dur<strong>in</strong>g the counsel<strong>in</strong>gprocessHow the practitioner responds willdeterm<strong>in</strong>e if it <strong>in</strong>creases or decreases


Decreas<strong>in</strong>g Resistance• F<strong>in</strong>d What you can agree with• F<strong>in</strong>d someth<strong>in</strong>g to affirm, even withnegatives loom• F<strong>in</strong>d positive reasons <strong>for</strong> negativebehavior


“MI Sandwich”Remember to use the “spirit” ofMotivational Interview<strong>in</strong>g dur<strong>in</strong>g this firstcontact with <strong>clients</strong>


Review of M.I.What is MI?Stephen Rollnick, Ph.D., & William R. Miller,Ph.D.Repr<strong>in</strong>ted with permission from Rollnick S., &Miller, W.R. (1995). What is motivational<strong>in</strong>terview<strong>in</strong>g? Behavioural and CognitivePsychotherapy, 23, 325-334.


Review of M.I.Def<strong>in</strong>itionOur best current def<strong>in</strong>ition is this: Motivational<strong>in</strong>terview<strong>in</strong>g is a directive, client-centeredcounsel<strong>in</strong>g style <strong>for</strong> elicit<strong>in</strong>g behavior changeby help<strong>in</strong>g <strong>clients</strong> to explore and resolveambivalence. Compared with nondirectivecounsel<strong>in</strong>g, it is more focused and goaldirected.The exam<strong>in</strong>ation and resolution ofambivalence is its central purpose, and thecounselor is <strong>in</strong>tentionally directive <strong>in</strong> pursu<strong>in</strong>gthis goal.


The Spirit of M.I.We believe it is vital to dist<strong>in</strong>guish between thespirit of motivational <strong>in</strong>terview<strong>in</strong>g andtechniques that we have recommended tomanifest that spirit. Cl<strong>in</strong>icians and tra<strong>in</strong>erswho become too focused on matters oftechnique can lose sight of the spirit and stylethat are central to the approach. There are asmany variations <strong>in</strong> technique there are cl<strong>in</strong>icalencounters. The spirit of the method,however, is move endur<strong>in</strong>g and can becharacterized <strong>in</strong> a few key po<strong>in</strong>ts.


“MI Spirit”:• Express Empathy• Develop Discrepancy• Roll with Resistance• Support Self-Efficacy


Motivational Interview<strong>in</strong>g Techniques“How can I implement a few M.I.techniques <strong>in</strong> my practice?”


OARSOpen-ended questionsAffirmationsReflectionsSummaries


OARSOpen-Ended Questions, Affirmations,Reflections, and Summaries help to:• Establish rapport and an atmosphere ofacceptance and trust• Set a precedent that the client has an active role• Promote client discovery of the important issuesand how they want to beg<strong>in</strong> the change process• Guide and steady the therapy process throughrough waters and uncerta<strong>in</strong>ty


Affirmation• Recogniz<strong>in</strong>g and affirm<strong>in</strong>g people‟s strengths,ef<strong>for</strong>ts, values, successes, skills, etc.• Helps <strong>in</strong>crease self-efficacy• Teaches client to recognize own strengths• Sends message that others believe <strong>in</strong> them andsupport their ef<strong>for</strong>ts.• Show that the counselor understands andappreciates at least part of what the client isdeal<strong>in</strong>g with.


Open-Ended QuestionsOpens dialogue with the client (be<strong>for</strong>e jump<strong>in</strong>g<strong>in</strong>to a <strong>for</strong>mal assessment)Can be used to elicit pert<strong>in</strong>ent <strong>in</strong><strong>for</strong>mation, aswell as learn the perspective of the client:“What are some reasons why you feel thisappo<strong>in</strong>tment was recommended <strong>for</strong> you?”“From your perspective, why do you th<strong>in</strong>k youwere referred <strong>for</strong> substance abuse counsel<strong>in</strong>g?”“What are your thoughts about be<strong>in</strong>g heretoday?”


Examples of Affirmations“This is hard work you are do<strong>in</strong>g.”“It takes courage to make this k<strong>in</strong>d of change.”“I really appreciate how much you shared today.”“Based on what you‟ve said, I can tell that youreally care about be<strong>in</strong>g a good mother.”“You have coped with some difficult situations.”“You‟ve come up with some great ideas aboutwhat it will take to keep mov<strong>in</strong>g <strong>for</strong>ward.”


Reflections:• Convey empathy and understand<strong>in</strong>g• Invite <strong>clients</strong> to fully explore issues• Can be used to guide discussion, to exploreand resolve ambivalence• Invites <strong>clients</strong> to provide <strong>in</strong>stant feedback.• There are different types and levels ofreflections. (to be covered soon)


Form<strong>in</strong>g Reflections:Use your tone of voice to dist<strong>in</strong>guish a reflectionfrom a question. Tone that goes down at theend is a statement/reflection. Tone that goesup sounds like a closed-ended question.Gett<strong>in</strong>g Started:“Sounds like you…”“It seems to you that…”“You‟re wonder<strong>in</strong>g if…”“So you feel…”“ You‟re say<strong>in</strong>g…”“You….”


How to Summarize• Str<strong>in</strong>g several reflections together,highlight<strong>in</strong>g the most important po<strong>in</strong>ts.• Include some content and some emotion.• Try to <strong>in</strong>clude an affirmation.• Set up: “Let me see if I have this right..”• Check <strong>in</strong>: “What else would you like toadd?”, “Now, tell me about...”, “Wheredoes that leave us?”


“What if I don‟t get it right?”Many cl<strong>in</strong>icians worry that they will misrepresent theclient or “get it wrong” <strong>in</strong> their reflections orsummaries.That’s okay!The client will appreciate that you are try<strong>in</strong>g and itgives them the chance to clarify.Reflections are one way of test<strong>in</strong>g theories. Sometimesthey fit and help the client ga<strong>in</strong> <strong>in</strong>sight.Don‟t be too afraid to take some risk. A complexreflection/summary often can add depth and emotion.Even if it is not quite accurate, the client is now<strong>in</strong>vited to go to that deeper level and specify what theymeant or felt.


Reflect ResistanceCl<strong>in</strong>ician: And tell me a little about yourdr<strong>in</strong>k<strong>in</strong>g (open question)Client: Well, I do dr<strong>in</strong>k most days, but not thatmuch, reallyCl<strong>in</strong>ician: You‟re a pretty light dr<strong>in</strong>ker(reflection)Client: Well, I‟m not sure about that/ I can holdit pretty well, more than mostCl<strong>in</strong>ician: You can dr<strong>in</strong>k a fair amount and itdoesn‟t seem to affect you (reflection)


Let your Clients helpTeach you M.I.• Let “resistant” behaviors be your cue to changestrategies, slow down, go back to basics, etc.• Your <strong>clients</strong> will teach you how to be MIconsistent if you are m<strong>in</strong>dful.• If it seems that you are work<strong>in</strong>g much harderthan the client, perhaps you have moved aheadprematurely or been too focused on promot<strong>in</strong>gyour sense of what the <strong>clients</strong> goals should be.• When <strong>in</strong> doubt, remember the SPIRIT of MI isgreater than the strategies.


Ask<strong>in</strong>g Permission“Ask<strong>in</strong>g permission…honors the person‟sautonomy and makes it easier <strong>for</strong> him or her tohear and consider what you have to say.”(Miller & Rollnick, 2002, page 132)*even dur<strong>in</strong>g the assessment process


AssessmentKey po<strong>in</strong>t: Ongo<strong>in</strong>g assessment occursthroughout the <strong>treatment</strong> episode, and not justdur<strong>in</strong>g the assessment session


Supervision ReviewRem<strong>in</strong>der: Assessments do need to be reviewedand “signed off” by a cl<strong>in</strong>ical supervisor if theassess<strong>in</strong>g cl<strong>in</strong>ician is still at an <strong>in</strong>tern status:Electrical note: Chart note that <strong>in</strong>dicates asupervisor has reviewedHard Chart: Full signatures andlicensure/license number


Questions?Any questions on:What is a <strong>treatment</strong> episode?Screen<strong>in</strong>g?Assessment?ASAM?Stages of Change?Diagnos<strong>in</strong>g?Motivational Interview<strong>in</strong>g?Module 1?


Module 2• Admission• Master Problem List• Treatment Plann<strong>in</strong>g• Add Reviews• Monthly ASAM (HDPC)• Changes <strong>in</strong> Treatment Plan


Admission-NHIPPSS<strong>in</strong>gle Service Level Episode - BasicAdmission Process:Once the client has been assessed and asubstance diagnosis has been rendered, youcan create an Admission record <strong>for</strong> him or her.The Admission record is filled out at the time aclient is admitted.. .all of the SAPTA andSAMHSA required data (<strong>for</strong> NOMS) iscaptured when fill<strong>in</strong>g out this <strong>for</strong>m.


AdmissionIt is important to be as accurate as possible whenenter<strong>in</strong>g <strong>in</strong><strong>for</strong>mation <strong>in</strong> the Admission record.This <strong>in</strong><strong>for</strong>mation is go<strong>in</strong>g to be compared with the<strong>in</strong><strong>for</strong>mation entered <strong>in</strong> the Discharge record todeterm<strong>in</strong>e if and how those areas identified <strong>in</strong> theNOMs have changed.This data is aggregated with the data <strong>for</strong> allsubstance abuse <strong>treatment</strong> providers and used todeterm<strong>in</strong>e how successful SAMHSA-fundedprograms are.The success of a state‟s NOMs can help determ<strong>in</strong>ehow much fund<strong>in</strong>g the state receives.


Admission cont.Additionally, here are a few th<strong>in</strong>gs to remember:• Only service levels <strong>for</strong> which your <strong>treatment</strong>location is certified can be saved <strong>in</strong> theAdmission record.• Once an Admission record is created <strong>for</strong> aclient, all subsequent Admission recordsshould be created by either a Transfer or Copyfunction. This preserves the <strong>in</strong>tegrity of theClient ID number generated <strong>in</strong> the Admissionrecord.


Treatment Plann<strong>in</strong>gTreatment plann<strong>in</strong>g is essential<strong>for</strong> good cl<strong>in</strong>ical practice!


Treatment PlanA Severity Rat<strong>in</strong>g of six or greater <strong>in</strong> anyassessment category will automatically createan associated problem <strong>in</strong> the Treatment Plan<strong>for</strong> any answer that is not a default value, suchas zero or “None Selected.” Likert scale rat<strong>in</strong>gsof Moderate or higher will typically result <strong>in</strong> aproblem be<strong>in</strong>g automatically generated <strong>in</strong> theTreatment Plan.


Treatment Plann<strong>in</strong>gIn Brief:First Treatment plan to be completed by thirdcl<strong>in</strong>ical contactIdentifies progress <strong>in</strong> client‟s <strong>treatment</strong> episodeReflects changes <strong>in</strong> client progressIs to be reviewed at a m<strong>in</strong>imum of every 14/30daysIs to be signed by the client (and markedcomplete if <strong>in</strong> NHIPPS)


Master Problem List• Once the assessment is completed, NHIPPSwill allow you to create a system- generated<strong>treatment</strong> plan that may conta<strong>in</strong> numerousproblems revealed <strong>in</strong> the assessment process.• The goal of the first draft or version of the<strong>treatment</strong> plan is to set up a work<strong>in</strong>g plan sothat you and your client can beg<strong>in</strong> to worktogether to improve his or her condition.


Master Problem List cont.S<strong>in</strong>ce the first version of the <strong>treatment</strong> planconta<strong>in</strong>s all of the problems from theassessment, you can also set this version up asthe „Master Problem List‟ and refer to itthroughout the course of <strong>treatment</strong>.


Master Problem ListTIP: To remove a problem from subsequentversions of the <strong>treatment</strong> plan, mark the statusof that problem as “Withdrawn” or “Resolved.”Problems with a status of withdrawn orresolved will rema<strong>in</strong> <strong>in</strong> the previous version.They will not appear <strong>in</strong> the next version of the<strong>treatment</strong> plan.


Treatment Plann<strong>in</strong>gWrit<strong>in</strong>g Effective Goals, Objectives and Strategies• Goals, objectives and strategies are the most important partof the <strong>treatment</strong> plan. This is where you, the cl<strong>in</strong>ician, havethe opportunity to help the client develop an effective courseof <strong>treatment</strong>.• A problem is a specific statement or issue that can be tied tothe client‟s substance use/abuse.• A goal is a behavioral statement of what is to be achieved <strong>in</strong>relation to that problem. This may not be easily measurableor quantifiable. For each problem that will either be treated orcase managed, the cl<strong>in</strong>ician develops a goal that, whenreached, will demonstrate that the client has resolved theproblem.


Treatment Plann<strong>in</strong>g• An objective is a specific statement of what the clientwill do to achieve the goal. An objective should bemeasurable with an amount, frequency, and duration<strong>for</strong> the def<strong>in</strong>ed task.• NHIPPS NOTE: If the status of your Objective is “InProgress” it will appear <strong>in</strong> the Progress Note.• A strategy is a specific statement of the <strong>in</strong>terventionor what the counselor and client will do together tohelp the client achieve the objective. This should alsobe measurable by amount, frequency and duration <strong>for</strong>the def<strong>in</strong>ed task.


Treatment Plann<strong>in</strong>g cont.Below are good examples of goals and their correspond<strong>in</strong>g objectivesand strategies.• Problem: The client lives at home with an activealcoholic (mother).• Goal: Client will actively seek another liv<strong>in</strong>g situation toreduce risk of exposure to alcohol.• Objective: Client will contact at least one (amount)potential residence per day (frequency) and record<strong>in</strong><strong>for</strong>mation gathered on agency <strong>for</strong>m to be reviewed onMM/DD/YYYY (duration).• Strategy: Counselor will give client a list of six low<strong>in</strong>come hous<strong>in</strong>g places to call and will follow up <strong>in</strong>therapy session on progress. (Amount, frequency andduration are recorded <strong>in</strong> the fields below strategydescription.)


Treatment Plann<strong>in</strong>g• Problem: The client has bereavement issues regard<strong>in</strong>gher brother‟s recent suicide that she believes havecontributed to her cont<strong>in</strong>ued substance abuse.• Goal: Client will identify bereavement issues <strong>in</strong> relation tousage.• Objective: Client will complete Exercises 1 through 5(amount & frequency) <strong>in</strong> “Good Grief” and “Wak<strong>in</strong>g upAlive” workbooks by MM/DD/YYYY (duration).• Strategy: Counselor and client will review completedbereavement exercises <strong>in</strong> <strong>in</strong>dividual therapy sessions andwill share problems/progress <strong>in</strong> group sessions.(Amount, frequency and duration are recorded <strong>in</strong> the fieldsbelow strategy description.)


Treatment Plann<strong>in</strong>gNOTE: The <strong>treatment</strong> plan status should be “InProgress” only when the <strong>treatment</strong> plan isbe<strong>in</strong>g edited. Otherwise, it should be <strong>in</strong>“Completed” status because the hard copy willhave both the client‟s and the counselor‟ssignatures.


Chang<strong>in</strong>g the Treatment PlanS<strong>in</strong>gle Service Level Episode - Chang<strong>in</strong>g theTreatment PlanIn NHIPPS, you cannot actually change a<strong>treatment</strong> plan once it has been marked complete.As with any signed document, whether electronicor on paper, it is important to have a copy of theorig<strong>in</strong>al. To allow changes to the current<strong>treatment</strong> plan, NHIPPS requires you to copy that<strong>treatment</strong> plan, thus creat<strong>in</strong>g a new, editableversion based on the previous version. This allowsyou to make the necessary changes that may be aresult of your <strong>treatment</strong> plan review.


Chang<strong>in</strong>g the Treatment PlanIf you are mak<strong>in</strong>g major changes to the <strong>treatment</strong> plan, suchas a change to the course of <strong>treatment</strong>, then you must do areview as well.For example, if you refer a client out to a local adult educationcenter to get a GED and they succeed, you would need tochange the <strong>treatment</strong> plan to reflect that progress.At that time, a review may not be necessary because thismilestone may not affect the course of the client's <strong>treatment</strong>.However, if you discover a new problem as you build yourrelationship with your client that contributes to theirsubstance use or causes a change <strong>in</strong> the course of <strong>treatment</strong>,you would edit the <strong>treatment</strong> plan to <strong>in</strong>clude that problemand you would also do a <strong>treatment</strong> plan review.


Changes <strong>in</strong> the Treatment PlanAga<strong>in</strong>, reasons to change the <strong>treatment</strong> plan<strong>in</strong>clude:• Reflect<strong>in</strong>g progress• Add<strong>in</strong>g problems or objectives (due toapproaches not work<strong>in</strong>g well or be<strong>in</strong>gcompleted, yet the problem needs additionalwork <strong>for</strong> resolution).


Add ReviewWhen you click on the Add Review button,NHIPPS takes you to the Service Plan Review.All of the problems that appeared on the<strong>treatment</strong> plan that have a status of “Treat” or“Case Management” will show up <strong>in</strong> thereview.


Add Review


ASAM/HDPC & TreatmentPlann<strong>in</strong>gRemember: ASAM drives <strong>treatment</strong>:Pert<strong>in</strong>ent <strong>in</strong><strong>for</strong>mation documented <strong>in</strong> the ASAMsummary needs to be reflected <strong>in</strong> the<strong>treatment</strong> planA review of the <strong>treatment</strong> plans and a review ofthe ASAM must be completed a m<strong>in</strong>imum of30 days <strong>for</strong> Outpatient and 14 days <strong>for</strong>Residential <strong>treatment</strong> episodes


ASAM ReviewOnce you have reviewed and adjusted severityrat<strong>in</strong>gs on dimensions, you will need to write anew cl<strong>in</strong>ical summary with the behavioraldetails that support your rat<strong>in</strong>gs. You will alsoneed to identify those dimensions driv<strong>in</strong>g yourrecommendation to either keep the client atthe current level of care or move them to adifferent level of care. Be sure to <strong>in</strong>corporatethe current diagnosis <strong>in</strong> this summary.


Example:“ Sylvia reports abst<strong>in</strong>ence from substances <strong>for</strong> over 2 months. She has been <strong>in</strong> controlledenvironments <strong>for</strong> most of that time. She is drug tested by Pretrial and not had any positive drugtests s<strong>in</strong>ce go<strong>in</strong>g to <strong>in</strong>patient <strong>treatment</strong>. Sylvia does not present with or report any withdrawalsymptoms and she has had time to detox with supervision. 2. Sylvia experiences some headachesand toothaches. She takes OTC meds <strong>for</strong> the pa<strong>in</strong> currently, but has no immediate way to get herdental problems treated. At this time, her medical problems are unlikely to <strong>in</strong>terfere with<strong>treatment</strong>, but unmanaged physical pa<strong>in</strong> could <strong>in</strong>crease her risk <strong>for</strong> relapse if not dealt with. 3.Sylvia is worried about her legal problems, unemployment, and family problems. She seemsmotivated to use positive cop<strong>in</strong>g skills, but has had little time to deal with similar problems whilenot us<strong>in</strong>g substances. 4. Sylvia appears motivated and is considered to be <strong>in</strong> the Action stage ofchange. She has completed <strong>in</strong>patient <strong>treatment</strong> successfully and is open to cont<strong>in</strong>u<strong>in</strong>g withoutpatient now. 5. Sylvia is at moderate risk <strong>for</strong> relapse because she is still <strong>in</strong> early recovery andhas a variety or stressors to deal with. She will be learn<strong>in</strong>g, review<strong>in</strong>g, and apply<strong>in</strong>g many newrelapse prevention skills. 6. Sylvia <strong>in</strong>dicates that she is <strong>in</strong> a positive home environment with herfamily. However, there is some stress because the family is struggl<strong>in</strong>g to trust her. She hassupport from her girlfriend, but no other peers. Sylvia is currently unemployed and look<strong>in</strong>g <strong>for</strong>work. She is closely monitored by Pretrial. Based on DSM-IV diagnoses of 304.40 Amphetam<strong>in</strong>eDependence- Early Full Remission, 309.24 Adjustment Disorder With Anxiety, V61.80 Sibl<strong>in</strong>gRelational Problem, and driv<strong>in</strong>g dimensions 3, 5, and 6, and crim<strong>in</strong>al justice referral, Sylvia isrecommended to participate <strong>in</strong> weekly, <strong>in</strong>dividual counsel<strong>in</strong>g”.


Activity 1: Treatment Plann<strong>in</strong>gChoose a partnerReview your vignetteDevelop an ASAM & Treatment Plan based onthe clientExchange and provide feedback on one another‟s<strong>treatment</strong> plan


Module 3• Progress Notes• Chart Notes• Client‟s progress <strong>in</strong> Treatment


Progress NotesProgression throughout the episode (progressbetween sessions)Topics can <strong>in</strong>clude ASAM dimensions addressed<strong>in</strong> sessionContent of session<strong>Cl<strong>in</strong>ical</strong> observationsCl<strong>in</strong>ician <strong>in</strong>terventions


Progress NotesEvery therapeutic event should be properly documented <strong>in</strong>NHIPPS. Progress notes are tools to allow cl<strong>in</strong>icians to trackthe progress of each client <strong>in</strong> <strong>treatment</strong>. They also allowproviders to track the services be<strong>in</strong>g delivered by theirprograms. Agency per<strong>for</strong>mance statistics are also countedfrom the units of service recorded <strong>in</strong> the progress notes.NOTE: SAPTA uses progress notes to tally the service unitsand track provider per<strong>for</strong>mance toward their negotiatedscopes of work. Each provider makes a commitment toSAPTA to treat a certa<strong>in</strong> number of <strong>clients</strong> and offer acomprehensive system of <strong>treatment</strong> services. SAPTA alsoexam<strong>in</strong>es contents of client files and reviews appropriatenessof client activities and documentation.


If a Client has a Treatment PlanThe objectives (“<strong>in</strong> progress) of the client will beavailable to address with each progress note.This is why it is important to personalizeobjective goals and not focus on programfocusedgoals-as <strong>in</strong>, “Client will submitrandom UAs”


Progress NotesA progress note is required <strong>for</strong> all cl<strong>in</strong>ical events suchas <strong>in</strong>dividual or group therapy sessions. In some cases,such as <strong>for</strong> residential services, therapeutic eventsoccurr<strong>in</strong>g over a number of days can be comb<strong>in</strong>ed <strong>in</strong>toone progress note. In this case, the units would equalthe number of days covered by the progress note, andclient activities would be recorded <strong>in</strong> daily chart notes<strong>for</strong> summarization <strong>in</strong>to a weekly progress note.Rem<strong>in</strong>der: When a <strong>treatment</strong> plan objective is be<strong>in</strong>greplaced with another because the client isn‟tachiev<strong>in</strong>g the desired results, or if it is resolved, thestatus of that objective should be changed so onlycurrent objectives appear <strong>in</strong> the NHIPPS ProgressNotes.


Sample of Progress Notes-TopicsExamples of TOPICS section of the Progress Notes.Met with Curt <strong>for</strong> 60 m<strong>in</strong>s. Discussed alcohol abst<strong>in</strong>ence. Began address<strong>in</strong>galternative ways he might deal with his physical pa<strong>in</strong> and also enjoyleisure/relaxation without dr<strong>in</strong>k<strong>in</strong>g. Driv. Dims. 2, 3, 5.ASAM 2, 3, and 6. Court trial on 4/16, allergies, relationship with father,substance abuse.Met with Garlen <strong>for</strong> 50 m<strong>in</strong>s. Discussed problems with his impulsivity andreactions to certa<strong>in</strong> th<strong>in</strong>gs. Addressed self control and th<strong>in</strong>k<strong>in</strong>g errors. Driv.Dims. 3, 6.Met with Eric <strong>for</strong> 50 m<strong>in</strong>s. Discussed stress related to work, school, and legalresponsibilities. Addressed how he is manag<strong>in</strong>g while prevent<strong>in</strong>g relapse.Driv. Dims. 3, 5,


Examples of Observations-EBPExamples of OBSERVATIONS section <strong>in</strong> the Progress notes.Client displayed self-critical th<strong>in</strong>k<strong>in</strong>g. Client was relaxed dur<strong>in</strong>gsession, did not dose off, and was actively engaged <strong>in</strong> therapy.Garlen presented with a bright affect. He still has a high level ofenergy, but it was not distract<strong>in</strong>g today. He was able toengage <strong>in</strong> mean<strong>in</strong>gful discussions.Eric was noticeably more irritable today and agreed with thereflection when offered. Eric cont<strong>in</strong>ues to present with adesire to cont<strong>in</strong>ue mak<strong>in</strong>g positive changes and shares a lot ofhope.


Examples of Observations-EBPGarlen presented with a fairly normal affect today.He engaged <strong>in</strong> discussion without go<strong>in</strong>g off track.He smiled a lot. He did not seem as restless orfidgety.Client was tearful <strong>for</strong> most of the session. Sheengaged openly, as usual.Noted that client was very restless, he rubbed hiseyes and scratched a lot. When therapist notedcondition to Shawn he did not seem aware that hewas do<strong>in</strong>g these actions.


Progress Notes-Intervention“ Reviewed relapse risks associated with boyfriend,certa<strong>in</strong> places, and emotions. Helped clientidentify a plan to avoid situations she deemed arisk to her abst<strong>in</strong>ence. Reflected that only clientcan choose what to do about relationship topromote self-efficacy. Used open ended questionsto have client look <strong>for</strong>ward to what life might bylike <strong>for</strong> her if she becomes s<strong>in</strong>gle. Did partialdecisional balance verbally with client to help herbeg<strong>in</strong> to consider good th<strong>in</strong>gs and not so goodth<strong>in</strong>gs about keep<strong>in</strong>g and about end<strong>in</strong>grelationship.”


Intervention EBP“Counselor taught client *I statements* throughmodel<strong>in</strong>g and role-play<strong>in</strong>g. Praised client <strong>for</strong>practic<strong>in</strong>g skill well. Promoted client self efficacyby hav<strong>in</strong>g her identify options and what she wants<strong>in</strong> a relationship. Developed discrepancy byreflect<strong>in</strong>g that what client has had and hopes tohave from her relationship are different than whatshe is currently gett<strong>in</strong>g from it. Discussed howstructure enhances relapse prevention andaffirmed her commitment to classes andcommunity service.”


Intervention EBP“Utilize MI and Solution focused techniques ofopen ended question, re-fram<strong>in</strong>g,compliment<strong>in</strong>g and establish<strong>in</strong>g acollaborative atmosphere to explore Shawnsfeel<strong>in</strong>gs about his substance use and his legalissues. To see Shawn <strong>in</strong> 1 week.”


Intervention EBP“As stated above, completed FAB and expla<strong>in</strong>edrationale to client. Po<strong>in</strong>ted out how different partsof the FAB will lead to new <strong>treatment</strong> objectivesand motivations. Dur<strong>in</strong>g work on FAB, discussedth<strong>in</strong>k<strong>in</strong>g errors that seem to lead back to addictivebehavior. Identified some replacement thoughts.Worked towards enhanc<strong>in</strong>g self efficacy by hav<strong>in</strong>gclient identify past accomplishments and his ownstrengths/skills. Used specific affirmations basedon experience with client to re<strong>in</strong><strong>for</strong>ce his ef<strong>for</strong>tsand abilities.”


Intervention EBP“Used solution focused strategies to emphasize selfefficacyby po<strong>in</strong>t<strong>in</strong>g out that Eric*s own list ofqualities and past successes shows he is quitecapable of change and success. Used MI scal<strong>in</strong>gquestion to assess confidence. Reflected changetalk he used such as, *I know I can do this*. UsedCBT relapse prevention strategies: referr<strong>in</strong>g toFAB, discussed how people have been triggers <strong>in</strong>some ways. Asked client about the risk peoplehave and could pose to his change, and begandiscuss<strong>in</strong>g options <strong>for</strong> reduc<strong>in</strong>g/manag<strong>in</strong>g thatrisk.”


Intervention EBP Language“Used open ended questions and reflections to elicitCurt*s perspective on alcohol and how he mightimprove his quality of life. Used affirmations tosupport his personal strengths and to support selfefficacy. Used open questions and CBT concepts toexplore with Curt the situations, thoughts, feel<strong>in</strong>gsthat led up to recent fleet<strong>in</strong>g desire to dr<strong>in</strong>k to helpenhance his understand<strong>in</strong>g of triggers. Beganexplor<strong>in</strong>g options <strong>for</strong> replacement activities s<strong>in</strong>ce hecannot dr<strong>in</strong>k or go to the Lake like he used to <strong>for</strong>relaxation.”


Intervention-EBP“Used motivational <strong>in</strong>terview<strong>in</strong>g techniques(open-ended ques., reflections, affirmations)to have client recall how change is importantto her with or without her boyfriend <strong>in</strong> her liferight now. Reviewed the importance of relapseprevention plann<strong>in</strong>g and tools that can helpher get through crav<strong>in</strong>gs. Used cognitivebehavioral strategies to challenge th<strong>in</strong>k<strong>in</strong>gerrors and self-defeat<strong>in</strong>g thoughts. Helpedclient identify more positive, realistic ways to<strong>in</strong>terpret the situation.”


Chart NotesDifferent from Progress notes (also capturesComprehensive evaluation units)Can be personalizedTo be used as necessary-helps withcommunicationCannot be deleted, however, can be editedOften used to <strong>in</strong>dicate lab results,communication with client, cancellations, etc.


Module 4• Aftercare Plan• Discharges• Conclusion


After Care Plan• What is <strong>in</strong>cluded <strong>in</strong> an aftercare plan?• How is this tied to the RecoveryOriented Systems of Care (ROSC)model?


DischargesDischarges are filled out whether the client leaves atthe completion of <strong>treatment</strong>, leaves aga<strong>in</strong>st theadvice of the counselor, or disappears completely.If the client leaves aga<strong>in</strong>st advice, you still need todischarge the client. Any active admission must bedischarged <strong>in</strong> NHIPPS. NHIPPS will rem<strong>in</strong>d you ifthere are <strong>clients</strong> that are admitted but notreceiv<strong>in</strong>g services. There are also reports <strong>in</strong>NHIPPS to help you track these numbers. Anyclient leav<strong>in</strong>g a <strong>treatment</strong> level should bedischarged <strong>in</strong> the system with<strong>in</strong> five days ofleav<strong>in</strong>g.


DischargesNOTE: It's important to be aware that while<strong>clients</strong> may leave be<strong>for</strong>e they complete<strong>treatment</strong>, when a discharge record <strong>in</strong>dicatesthat the client completed <strong>treatment</strong> it is criticalto accurately answer the questions related toNOMs, specifically Employment Status, Liv<strong>in</strong>gArrangement, and Frequency ofUse. Otherwise there will be a negative impactto the state outcome measures.


Discharge SummaryWhat is <strong>in</strong>cluded <strong>in</strong> a discharge summary?If the client successfully completes <strong>treatment</strong>If the client is transferred to a different level ofcareIf the client stopped attend<strong>in</strong>g sessionsaltogether (no call/no show)If the client left residential services AMAIf the client became <strong>in</strong>carcerated <strong>for</strong> over 30days


Discharge SummariesIdeally to be completed with the client as it<strong>in</strong>cludes goals <strong>for</strong> cont<strong>in</strong>uum of careIs detailed so client can understand any furtherrecommendationsCan <strong>in</strong>clude identified strategies <strong>for</strong> relapsepreventionIs MeasurableIncludes pert<strong>in</strong>ent <strong>in</strong><strong>for</strong>mation regard<strong>in</strong>g DSM-IV dx, completion of <strong>treatment</strong>, follow-up<strong>in</strong>structions


Signatures, Signatures, Signatures!As we shift towards electrical chart<strong>in</strong>g, it isimportant to remember to provide signatureson important documents, <strong>in</strong>clud<strong>in</strong>g:Forms, <strong>in</strong>clud<strong>in</strong>g consentsTreatment plansAfter care planAfter each charted documentation <strong>in</strong> hard chartAlso be m<strong>in</strong>dful of cross<strong>in</strong>g through blank<strong>for</strong>ms, and <strong>in</strong>itial/date when correct<strong>in</strong>g


Hard Charts


Hard ChartsOrganizedCo<strong>in</strong>cide with electrical chart<strong>in</strong>gSigned <strong>for</strong>msSignatures of cl<strong>in</strong>icians/supervisorsSecurely storedArchived appropriatelyUpdated as needed


Supervision <strong>Documentation</strong>As a supervisor:Regularly review documentation from your<strong>in</strong>ternsTrack recommendations discussed withyour <strong>in</strong>ternSign off as appropriateDocument observed session <strong>for</strong> Q.A.


Activity 2: You‟re the Supervisor!Partner upReview: AssessmentTreatment PlanProgress NoteDischarge SummaryReview <strong>for</strong> miss<strong>in</strong>g <strong>in</strong><strong>for</strong>mationRecognize strengths of cl<strong>in</strong>ician


<strong>Cl<strong>in</strong>ical</strong> <strong>Documentation</strong>Responsibilityof the cl<strong>in</strong>icianDemonstrateswork of theclient<strong>Cl<strong>in</strong>ical</strong><strong>Documentation</strong>Benefits theclientDemonstrateswork of thecl<strong>in</strong>ician


In Conclusion….Questions???

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