Progress Notes Training Packet | Greater New Beginnings, Lecture notes of Communication

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Progress Notes

Training Packet

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Service Types

Case Management [541, 561, 571]

“Targeted Case Management” (Case Management/ Brokerage/Linkage/Placement) means services that assist

a client to access needed medical, educational, social, pre‐vocational, vocational, rehabilitative, or other

community services. The service activities may include, but are not limited to, communication, coordination,

and referral; monitoring service delivery to ensure client access to service and the service delivery system;

monitoring of the client’s progress; placement services; and plan development.

*“Intensive Care Coordination” (Targeted Case Management for Katie A clients) means facilitating

assessment of, care planning for and coordination of services, including urgent services. Includes

assessment related to action planning and development/revision of action plans, referral, linkage,

monitoring and transition activities that address the use of natural and community supports.

“Collateral” means a service activity to a significant support person in a client’s life with the intent of

improving or maintaining the mental health status of the client. The client may or may not be present for this

service activity. Rehabilitation [317, 318, 355]

“Rehabilitation” means a service activity which includes assistance in improving, maintaining, or restoring a

client’s or group of clients’ functional skills, daily living skills, social and leisure skills, grooming and personal

hygiene skills, meal preparation skills, and support resources; and/or medication education.

*“In Home Behavioral Support” (Mental Health Rehabilitation Services for Katie A clients) means

intensive, individualized, strength‐based interventions designed to ameliorate mental health

conditions that interfere with functioning and assist in building skills and developing replacement

behaviors necessary for success at home and in the community.

“Assessment” means a service activity which may include a clinical analysis of the history and current status of

a client’s mental, emotional, or behavioral disorder; relevant cultural issues and history; diagnosis; and the use

of testing procedures.

“Plan Development” means a service activity which consists of development of client plans, approval of client

plans, and/or monitoring of a client’s progress.

“Therapy” means a service activity which is a therapeutic intervention that focuses primarily on symptom

reduction as a means to improve functional impairments. Therapy may be delivered to an individual or group

of clients and may include family therapy.

“Medication Support Services” means those services which include prescribing, administering, dispensing and

monitoring of psychiatric medications or biologicals which are necessary to alleviate the symptoms of mental

illness. The services may include evaluation of the need for medication, evaluation of clinical effectiveness and

side effects, the obtaining of informed consent, medication education and plan development related to the

delivery of the service and/or assessment of the client. Crisis Intervention [371]

“Crisis Intervention” means a service, lasting less than 24 hours, to or on behalf of a client for a condition

which requires more timely response than a regularly scheduled visit. Service activities may include but are

not limited to assessment, collateral and therapy. Crisis intervention is distinguished from crisis stabilization by

being delivered by providers who are not eligible to deliver crisis stabilization or who are eligible, but deliver

the service at a site other than a provider site that has been certified by the department or a Mental Health

Plan to provide crisis stabilization.

351*]

Targeted Case Management vs. Rehabilitation

Department of Mental Health – Quality Assurance Unit For Training Purposes Only Last Revised 07 /2 0 / 2020

TCM (T1017) Service Components:  Assessment  Plan Development  Referral and Related Activities  Monitoring and Follow-up

What it is:  Services to assist client in accessing needed ancillary services (i.e. medical, dental, alcohol/drug treatment, educational, social, prevocational, rehabilitative, or other community services)  Services include linkage and consultation, placement, and plan development

Requirements:  Justify need for TCM service based on the client’s mental health symptoms/impairments  Evaluating for needs, planning, referral, and progress  Assisting client in gaining access to services and plan coordination when linking client to services and monitoring progress  Ensuring TCM services are being furnished in accordance with client treatment plan  Evaluating the adequacy of services/resources and adjusting plan accordingly

TCM activities:  Locating and securing appropriate resources  Monitoring the client’s access to services  Monitoring the client’s progress once access has been established

Key words when writing TCM note: Refer to Active Verbs/Phrases that Can Be Used to Document Targeted Case Management (TCM) Service Interventions

Rehabilitation (H2015) A Component of Mental Health Services:  Assessment  Plan Development  Therapy  Rehabilitation  Collateral

What it is:  A service delivered to a client to provide assistance in improving, maintaining, or restoring the client’s functional, daily living, social and leisure, grooming and personal hygiene, or meal preparation skills, or his/her support resources  Service activity provides assistance in restoring, improving, and/or preserving a client’s functional, social, communication, or daily living skills to enhance self-sufficiency or self-regulation

Requirements:  Must provide assistance in restoring, improving, or preserving the client’s functional level (i.e. skill building )  Focus should be on teaching skills , not doing the skill/activity for the client

Rehab activities:  Teaching the client social skills/communication skills/problem-solving skills/relaxation skills/anger management skills/assertiveness skills to promote self-sufficiency  Prompted the client to use healthy coping skill (e.g. deep breathing) to self-regulate while doing an activity

Key words when writing a Rehab note: Refer to section on Rehabilitation in Active Verbs/Phrases that Can Be Used to Document Mental Health Services (MHS) Interventions

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Intervention Phrase Examples

 acknowledged client’s need for improvement in …

 actively listened

 allowed client to openly express

 asked client to be mindful of

 asked exploratory, Socratic, open‐ended, directed, feelings‐related questions regarding

 assessed client’s mood by asking questions related to/about

 assisted client in

 brought to client’s attention

 checked in with client

 clarified the expectations for; asked for clarification around

 collaborated on/with

 congratulated client

 continually checked for appropriateness during

 demonstrated patience around...

 directed the client

 discussed client’s current behavior, coping skills, triggers, treatment plan

 empathized with

 encouraged client to express/use mindfulness/make alternative behavioral choices

about

 engaged in a feelings‐related conversation

 established clear boundaries

 explicitly stated and had client repeat for clarity

 explored client’s underlying feelings about

 expressed concern/cautioned about client’s words/actions/behaviors

 facilitated a conflict resolution/conversation between

 followed up with/on

 frequently checked back with client for the duration of the activity for

 granted client’s request…

 guided the client in a role play/ role‐played the situation so that client could experience

different outcomes

 helped client achieve goal #__ by; create a behavioral contract

 identified triggers, coping skills, boundaries…

 informed

 initially used planned ignoring so as not to positively reinforce the negative behavior but

then…

 isolated/insulated client from the situation and used active listening to

 made plans for client’s next interaction

 modeled various reactions to

For Training Purposes Only

ACTIVE VERBS/PHRASES THAT CAN BE USED TO DOCUMENT

INTENSIVE HOME BASED SERVICES (IHBS) INTERVENTIONS

*This is not an exhaustive list

Rehabilitation: Collateral: Assisted client with restoring/improving/preserving functioning in…(communication, daily living, etc.)…by…

Assisted significant support person in/with … to support client… Assist client with acquiring and improving/mastering …skill…

Assist significant support person with acquiring and improving/mastering …skill… Assisted client in/with…by developing skills in… Built capacity in …skill to support client with… Built capacity in …skill… Clarified skills building technique Clarified skills building technique… Coached significant support person… Cued… Demonstrated… Demonstrated… Developed …(strategies) with significant support person to support client with… Developed …(strategies) with client to address … Educated/informed significant support person… Discussed… Encouraged significant support person to assist client in… Directed/redirected… Enhanced knowledge on… Educated/explained/informed… Expanded knowledge on… Encouraged… Explained … to significant support person… Enhanced self-sufficiency by… Follow up on… Enhanced self-regulation by… Gave/provided feedback… Expand knowledge on… Guided significant support person… Established boundaries/set limits… Helped significant support person develop skills in…for… Focused/refocused… Instructed… Follow up on… Led significant support person in practicing… Gave/provided feedback… Modeled… Guided… Observed… Helped client develop skills in…for… Recommended… Instructed… Reinforced… Led client in practicing… Reviewed skills/techniques… Modeled… Role-played… Observed… Sought clarification of client progress and/or understanding of client condition or skills/technique… Recommended… Taught significant support person in … skill… Reinforced… Trained significant support person in … skill… Reviewed skills/techniques… Worked on… Role-played… Skill Building in … (advocacy/assertiveness training, conflict resolution, relaxation techniques, etc.) … to/for… Sought clarification of client progress and/or client understanding of skills/technique… Taught…skill… Trained…

For Training Purposes Only

ACTIVE VERBS/PHRASES THAT CAN BE USED TO DOCUMENT

MENTAL HEALTH SERVICES (MHS) INTERVENTIONS

*This is not an exhaustive list Assessment: Plan Development: Assessed for … (risks, strengths, trauma, etc.) Clarified plan… Analyzed… Coordinated… Completed assessment… Created/Developed plan for … (issues) (describe plan) Conducted assessment… Discussed planning… Determined… Established plan for… Evaluated… Evaluate effectiveness of plan… Gathered history… Explored plan options… Gathered information… Focused/refocused on planning… Reviewed… Gave feedback on plan… Tested… Helped client redefine plan… Modified/adjusted plan… Monitored adherence to plan recommendations… Planned for…

Rehabilitation: Collateral: Assisted client in/with…by developing skills in… Assisted significant support person in/with … to support client… Clarified skills building technique… Clarified skills building technique Cued… Coached significant support person… Discussed… Demonstrated… Directed/redirected… Educated/informed significant support person… Educated/explained/informed… Encouraged significant support person to assist client in… Encouraged… Expanded knowledge on… Established boundaries/set limits… Explained … to significant support person… Focused/refocused… Follow up on… Follow up on… Gave/provided feedback… Gave/provided feedback… Guided significant support person… Guided… Helped significant support person develop skills in…for… Helped client develop skills in…for… Led significant support person in practicing… Led client in practicing… Modeled… Modeled… Observed… Observed… Recommended… Recommended… Reinforced… Reinforced… Reviewed skills/techniques… Reviewed skills/techniques… Role-played… Role-played… Sought clarification of client progress and/or understanding of client condition or skills/technique… Skill Building in … (advocacy/assertiveness training, conflict resolution, relaxation techniques, etc.) … to/for…

Taught significant support person in … skill…

Sought clarification of client progress and/or client understanding of skills/technique…

Trained significant support person in … skill…

Taught…skill… Worked on…

For Training Purposes Only

ACTIVE VERBS/PHRASES THAT CAN BE USED TO DOCUMENT

INTENSIVE CARE COORDINATION SERVICES (ICC) INTERVENTIONS

*This is not an exhaustive list Planning and Assessment of Strengths & Needs:

Re-Assessment of Strengths & Needs:

ASSESSING: Approved updated plan with CFT members… Analyzed… Clarified/created/developed updated plan… Assessed/evaluated needs for… Completed/updated needs reassessment… Assessed/evaluated strengths… Contributed new information on … during CFT Meeting… Assessed/evaluated available resources… Determined if changes are necessary to address new needs… Assessed/evaluated available support networks… Discussed needs and strengths identified in CANS tool to develop or enhance plan… Completed needs assessment… Discussed new needs and strengths/gains… Contributed/provided needs assessment information about … during CFT Meeting…

Established need for continuation of ICC services…

Determined… Established plan to address new need… Discussed needs and strengths identified in CANS tool to develop plan…

Modified/adjusted plan…

Elicited information on needs from CFT Members… Reassessed/reevaluated needs and strengths… Established need for ICC services… Reassessed/reevaluated available resources… Gathered history… Reassessed/reevaluated available support networks… Gathered information… Refined plan… Identified needs/underlying needs… Revised plan… Identified strengths & protective factors/behaviors… Reviewed… (refer to Planning and Assessment of Needs and Strengths for additional verbs/phrases) PLANNING: Aligned/Approved plan with CFT members… Clarified plan… Coordinated… Created plan… Developed plan for… Developed strategies for… Discussed planning… Established plan for… Explored plan options… Explored barriers in plan and with adherence… Formulated positive intervention strategies… Focused/refocused on planning… Gave feedback on plan… Helped client redefine plan… Informed of … to develop plan… Participated in CFT Meeting by… Planned for… Prioritized needs to be addressed…

For Training Purposes Only

ACTIVE VERBS/PHRASES THAT CAN BE USED TO DOCUMENT

TARGETED CASE MANAGEMENT (TCM) SERVICE INTERVENTIONS

*This is not an exhaustive list Assessment: Referral & Related Activities: Analyzed… Assisted client in/with…by… Assessed/evaluated needs for… Coordinated linkage to ancillary services… Assessed/evaluated available resources… Coordinated linkage to community resources… Assessed/evaluated available support networks… Coordinated placement… Completed needs assessment… Discussed options in resources… Determined… Educated and informed about resource… Established need for or continuation of TCM services… Encouraged use of/engagement in…(linkage/referral)… Gathered history… Established communication between client and (resource)… Gathered information… Established connections between client and (resource)… Identified needs/potential needs… Facilitated client linkage to referral… Re-Assessed/re-evaluated needs for… Implemented needs plan… Re-Assessed/re-evaluated available resources… Linked client to…(resource) to address…(need)… Re-Assessed/re-evaluated available support networks… Obtained … to address … need… Reviewed… Referred client to…(resource) to address…(need)…

Plan Development: Monitoring & Follow Up: Approved plan… Adjust/modify/refine/rework plan… Clarified plan… Arranged services with providers after a change in the CTP… Coordinated… Clarified progress of plan… Created plan… Evaluated effectiveness of plan to meet needs… Determined if changes are necessary to plan… Follow-up to ensure plan is appropriately implemented… Developed plan for… Follow-up to monitor if plan addresses client needs… Discussed planning… Gave/Provided feedback… Established plan for… Monitored client’s response with plan… Explored plan options… Monitored adequacy of the plan… Explored barriers in plan and with adherence… Monitored adherence with the CTP… Focused/refocused on planning… Recommended… Gave feedback on plan… Reviewed… Helped client redefine plan… Summarized… Integrated strengths to expand on plan… Tracked progress in plan… Modified/adjusted plan… Monitored client’s progress to revise plan… Planned for… Refined plan… Revised plan… Updated plan…

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Billing for Multiple Staff

Multiple staff can be billed for when one of the below three conditions are met:

Safety

1. In crisis situations when the threat of danger to self or others has deemed the need for multiple staff in

order to reduce the risk of harm to any persons involved. The risk involved to meet this criteria is

above and beyond day‐to‐day workings with clients and is limited to circumstances in which staff do

not have the environmental support that would usually maintain safety, i.e. responding to a crisis call

in which a client is threatening the safety of his/her family)

2. In situations when client history deems it clinically necessary to double staff in order to maintain safer

circumstances such as reducing the risk of AWOL and/or aggressive acts. This must be indicated within

client’s tx plan, and a statement of explanation for the justification of two staff should be included at

the start of the note.

a. The tx plan should be regularly reviewed to determine if double staffing remains a necessity

and documentation of the client’s progress should be noted to determine the (in)effectiveness

of this support.

Meetings

1. For client‐based meetings that involve multiple parties (IEPs, TDMs, and CFTs) multiple staff can bill so

long as their contribution to the meeting is active, results in providing unique information from their

perspective and is not a passive participation where listening to the information being presented is the

essential role.

 Typically, two staff, but three staff may bill for Katie A ICC Child and Family Team Meetings

2. All billable staff are to clearly define the unique nature of their involvement by co‐authoring the note

and “signing off” on the documentation for accountability and to ensure accuracy of reporting.

3. All billable staff must to be present for the entire time billed.

Group Notes

1. When providing therapy or rehabilitation to multiple clients, multiple staff can be listed on the

documentation.

2. It is not necessary to define individual roles in this type of documentation, but both billing staff need to

be present throughout the entire duration of the group. Their presence needs to possess a clinical

relevance and they must participate continually throughout the duration of the session.

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How to Best Document Travel Time: Frequently Asked Questions

1. Can I bill travel time for time I spent in the car with my client while my client was

asleep/reading/staring out the window?

Any minutes spent with client when no interventions are provided should be reflected by non‐billable

time: even if service is occurring during a drive (client is sleeping, listening to music, playing on iPod).

We cannot bill for travel even if no other direct interventions are occurring. Travel time accounts only

for the minutes you spend traveling to a location, alone, to provide a service. Any time spent with the

client/family is either billable or non‐billable service time.

2. How do I account for travel time if I drove from home to provide my service?

When driving from “home” staff should reflect travel as if they had driven from their home site office

and only bill for travel as if it had originated from their office.

3. What if two staff have to travel to the same location, but have different travel

times (and authorship on the note is shared)?

The primary author of the note should bill for the average travel time of the two staff. Remember that the

travel time entered in the note will be portioned out to each billing staff.

Department of Mental Health – Quality Assurance Unit For Training Purposes Only Last Revised 07/20/

What Is Reimbursable and What Is Not?

Some required tasks are just part of the job, and cannot be claimed to Medi-Cal for Reimbursement.

Vocational Examples

Reimbursable Non-Reimbursable  Assist the client in considering how the Boss' criticism affects him/her and strategies for handling criticism.

 Visiting a client's job site to teach him/her a job skill.

 Responding to the employer's call for assistance when the client is in tears at work because client is having trouble learning a new cash register (self- regulate and concentrate on the task of learning the new skill).

 Providing hands-on technical assistance to the client regarding how to use a computer.

Educational Examples

Reimbursable Non-Reimbursable  Sitting with a client in a Community College class the first time and debriefing the experience afterward.

 Assisting the client with his/her homework.

 Assisting the client with the arithmetic necessary to help him/her manage their household budget.

 Teaching a typing class on site at an adult residential program in preparation for entry to a formal job training program.  Assisting a client to find tutorial help in English.

 Teaching an English class/typing class.

Recreational and Socialization Examples

Reimbursable Non-Reimbursable  Helping the client improve his/her communication skills during a recreational activity.

 Playing basketball with the client or taking them to the beach.

 Helping the client learn better social skills so he/she will be better able to interact with people.

 Playing cards or any other games with a client or groups of client.

Other Non-Reimbursable Activities

Non-Reimbursable  Travel time between two provider sites (two billing providers).  Explaining:  HIPAA & obtaining signature  Consent for Treatment & obtaining signature  Advanced Health Care Directive & obtaining signature.  Completing face sheets for opening clinical record.  Translation/Interpreter service.  Supervision time.  Services after the death of a beneficiary (client).  Leaving a note on a door or making a phone call from the location.  Scheduling or re-scheduling an appointment.  Phone calls to remind clients of appointments, including leaving a message on an answering machine.  Faxing, copying, emailing, and other clerical activity.  Completing SSI applications.  Transportation services.  Payee related services.  Conservatorship investigation.  Missed appointments (and no services provided).  Home or personal care services performed for the client.

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Caseload Time Blocking

Arrange your schedule according to client or parent schedules. Plug in paperwork time around already determined schedule & map out for the week. Here are some examples of time organization and management

8:00- 12: Mornings

Early Afternoon

Evenings -non-working parents -Preschool kids

• school observations
• independent study Collaterals  P.O  Social workers  Doctors - Modified school days - School observations - Transport/ linkage - Traditional schools - Working parents - After-school meetings

Example:

1. Make a task list for things to do If a client/collateral cancels: closing paperwork prep prior to final session, assessments, collaterals, back‐up client, or ask someone if they need assistance with transport etc…
2. Who is available in the mornings?
3. What parents can I meet with regularly as part of family therapy?
4. Estimate # of contacts per week needed and time.  School visits/ Meetings‐teachers, school counselors  Parent Education/ self‐regulation‐ while child is at school  Weekly contact with P.O. and SW 8:00- 12: Mornings

Early Afternoon

Evenings Monday 10 am Tommy- Parent Visit (2 Hrs.) 12:30pm- school visit- Sally (1:45) 3:00- ART transport (1 hour)

3:45- Renaldo- ind + family (2 hrs.)

Tuesday 8:30am Notes 10 am Benny collateral PO & parent (10:30)

11am school visit Tommy (lunch- observation/ skill building)

12:00 am Parent (lunch meeting) (1:27)

1:30-2:30 complete assessment Tommy/ review chart

3:00- Bill- Pick up from school (1:15) 4:30-Paula- Individual/ sibling- House rules (1:30)

Generally, 3 client contacts per day with collateral will help you achieve 65%

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Activity 3: Note Practice:

Behavior

Interventions

Response

Plan

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Activity 4: Case Management or Collateral?

Read the following examples and determine which service type best fits:

Example 1

This counselor (JP) greeted client and foster parents (FPs). JP engaged FPs in a discussion

regarding concerns with client including phone use in the home and mood regulation.

FP’s stated that they saw “excessive phone use” as a distraction from homework and

something that “triggers her bad mood.” The FP’s mentioned that phone use has

increased from approximately 30 minutes to 3 hours per night. JP told FP’s that client

has self‐reported increased anxiety and depression symptoms after a lot of time on the

phone. FP’s stated that they had just begun behavior modification chart for earned

phone time only after periods of respectful communication and homework completion.

Example 2

This counselor (JP) praised the client’s mother’s positive response to client’s recent

increased homework completion. JP acknowledged client’s mother for giving stickers,

verbal praise, and telling client aloud specific examples of desired behaviors (homework

completion, respectful communication and using coping skills when frustrated, per

client’s treatment goal.) JP highlighted specific structural elements included into visits

such as explanation of expectations prior to activities and development of reward

systems for positive behavior, introducing client’s mother to a potential video diary

project in which to involve this client. JP highlighted the benefits of this project, naming

the opportunity for the client to share the final product with family and friends in order

to underscore the client's strengths and develop positive relationships with family. JP

suggested that client’s mother continue the positive reinforcement and reminded her

that her own self‐care (continued AA meeting attendance to support her sobriety,

continued healthy eating, and healthy sleep hygiene) plays a key role in role modeling

for client.