I Introduction to Documentation Sec Terry Hamm Division of Behavioral Health Medicaid and Quality Section / Tribal Program Janice Hamrick, LCSW, BHP SouthEast Alaska Regional Health Consortium Community Family Service Program Manager

Our goal is to give you foundational information so that by the end of this training you feel better equipped!

Sec Introduction to Documentation Required class for all BHA I this is a foundational course

Here’s what required : (a)1 Foundational information regarding the establishment and maintenance of a quality client record, including the essential components of clinical/counseling records, including assessments, treatment plans, progress notes, discharge summaries, and authorizations for disclosure

(a)2 Foundational information regarding the purpose and elements of case narrative recording, including using data, assessment, and plan (“DAP”); subjective, objective, assessment and plan (“SOAP”); and other formats for case narrative recording;

(b)1 An introduction to the use of standardized information management systems and screening tools widely used by Alaska behavioral health programs; AST ? AST ?

(b)2An introduction to using criteria contained in the: Diagnostic and Statistical Manual American Society of Addiction Medicine (“ASAM”) Patient Placement Criteria (“PCC”) to standardize documentation in relation to treatment and service planning (problem list, goals, objectives, and interventions);

(b)3 An introduction to documentation requirements specific to prevalent payors and accrediting bodies, such as Medicaid, Medicare, Commission on the Accreditation of Rehabilitation Facilities (“CARF”), and The Joint Commission;

(b)4 An introduction to special documentation issues arising in family and group counseling and when recording information subject to special confidentiality conditions, such as information about infectious diseases;

(b)5An introduction to administrative record keeping;

(c)Applied exercises in which trainees practice documenting client related work and consider the effect of confidentiality rules on the application of documentation requirements.

We most often come to work in order to get paid in our work that means Documentation has to meet certain requirements that are laid out by: Medicaid, Medicare CARF JACHO So that agencies can get paid for services They provide…what does this mean?

Division of Behavioral Health Clinical Documentation Requirements Integrated BH Regulations Training April 2012 Version

A Full Clinical Record Includes: Every clinical record must include: The Alaska Screening Tool (AST) All clients seeking services at a Community Behavioral Health Services clinic must complete the AST and it must be completed before are any assessments completed The Client Status Review (CSR) The CSR must be completed at the first contact and then every 90 – 135 days as long as the person remains in services A Behavioral Health Assessment: Substance Use Assessment Mental Health Assessment Integrated Mental Health and Substance Use Assessment A Behavioral Health Treatment Plan based on the Assessment Progress Notes

The Role of the Behavioral Health Aide (BHA) All BHAs can assist Behavioral Health clients in completing: The AST The CSR If a BHA is a CDC Substance Use Counselor the BHA can: Complete a Substance Use Assessment Develop a Substance Use Treatment Plan All BHAs can provide Rehabilitation Services and write Progress Notes for the service as long as: The Rehabilitation Service is on the treatment plan and a directing clinician has assigned the BHA to the service

Progress Notes and State Regulations BHAs must write a Progress Note: For every service on the day of the service was provided Progress Notes cannot cover multiple days or multiple services For Medicaid Regulations Progress Notes Must Include: What service was provided Who provided the service What activities were part of the service What the BHA did during the service to guide the client How the client reacted What are the next steps Most important remember: NO PROGRESS NOTE = NO PAYMENT

Most important remember: NO PROGRESS NOTE = NO PAYMENT

can be written in several different formats, two we will discuss are the SOAP, the DAP

S = Subjective [Client’s view of problems or progress noted, use client’s own words.] O = Objective [BHA’s objective observations of the clients progress.] A = Assessment [BHA’s assessment of the client’s affect, mental status, and psychosocial functioning.] P = Plan [Plan for future treatment as it r relates to progress noted.]

S = Subjective Tonya: Tonya is in the clinic and says “I drink because it drowns out the voices so I won’t hurt myself and I feel better” She is unsure if this substance use has any connection to her feeling unsafe and worried about other out to get her.

O = Objective Tonya: BHA comments: Objective 1: “Within the next month Tonya will identify 5 ways that substances may have affected her life.” Objective 2: “Within the next month Tonya will identify one or more factors she views as benefits from reducing or eliminating the use of substances.”

A = Assessment

P = Plan

D = Data [BHA’s observations, what the BHA saw and heard, quote statements made by the client.] A = Assessment [The BHAS assessment of the client’s mental status and psychological functioning.] P = Plan [Plan for future treatment as it relates to progress noted and updating of the treatment plan.]

D = Data Tonya: Tonya, came to the clinic today. She was drinking last night and got into a fight with her boyfriend. Tonya stated “I had to drink because there were all these voices in my head and when the voices come I want to hurt myself. The booze takes the voices away, but then I get into fights and it hurts my kids” After talking we discussed the need that within the next month Tonya will come back tell me 5 ways that booze is affecting her life and she will find at least one reason why stopping or drinking less will help her life.

A = Assessment

P = Plan

questions to your instructor.