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Behavioral Health Care Fourth Edition

This fourth edition of A Practical Guide to Documentation for Behavioral Health Care is an update of a popular publication designed to help staff effectively prepare and use documentation that supports safe, high-quality care, treatment, and services. The examples throughout this book illustrate ways behavioral health care organizations have successfully documented assessments; plans of care, treatment, or services; and processes such as medication reconciliation, progress notes, and resource allocation and maintenance. Thoroughly revised and specifically for behavioral health care leaders and staff seeking to improve their documentation skills, this new edition also offers the following: • Expanded discussion on the growing use of electronic records • Focus on the “person-centered care” model that encourages individuals served to invest in their own recovery • New appendix providing relevant Joint Commission requirements related to documentation • Companion CD with customizable forms and a planning form exercise to help the user develop effective plans of care, treatment, or services

About Joint Commission Resources Joint Commission Resources (JCR) is an expert resource for health care organizations, providing consulting services, educational services, and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner. Please visit our website at http://www.jcrinc.com.

Joint Commission Resources (JCR), an affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission. 1515 West 22nd Street, Suite 1300W Oak Brook, IL 60523-2082 U.S.A. www.jcrinc.com

Item Number: BH12

A Practical Guide to Documentation in Behavioral Health Care, Fourth Edition

A Practical Guide to Documentation in

A Practical Guide to

Documentation in

Behavioral Health Care Fourth Edition

Behavioral Health Care Fourth Edition

This fourth edition of A Practical Guide to Documentation for Behavioral Health Care is an update of a popular publication designed to help staff effectively prepare and use documentation that supports safe, high-quality care, treatment, and services. The examples throughout this book illustrate ways behavioral health care organizations have successfully documented assessments; plans of care, treatment, or services; and processes such as medication reconciliation, progress notes, and resource allocation and maintenance. Thoroughly revised and specifically for behavioral health care leaders and staff seeking to improve their documentation skills, this new edition also offers the following: • Expanded discussion on the growing use of electronic records • Focus on the “person-centered care” model that encourages individuals served to invest in their own recovery • New appendix providing relevant Joint Commission requirements related to documentation • Companion CD with customizable forms and a planning form exercise to help the user develop effective plans of care, treatment, or services

About Joint Commission Resources Joint Commission Resources (JCR) is an expert resource for health care organizations, providing consulting services, educational services, and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confidential manner. Please visit our website at http://www.jcrinc.com.

Joint Commission Resources (JCR), an affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission. 1515 West 22nd Street, Suite 1300W Oak Brook, IL 60523-2082 U.S.A. www.jcrinc.com

Item Number: BH12

A Practical Guide to Documentation in Behavioral Health Care, Fourth Edition

A Practical Guide to Documentation in

A Practical Guide to

Documentation in

Behavioral Health Care Fourth Edition

A Practical Guide to

Documentation in

Behavioral Health Care Fourth Edition

Senior Editor: Robert A. Porché, Jr. Project Manager: Andrew Bernotas Manager, Publications: Lisa Abel Associate Director, Production: Johanna Harris Executive Director: Catherine Chopp Hinckley, PhD Joint Commission/JCR Reviewers: Lynn M. Berry, JLA; Mary Cesare-Murphy, PhD; Sophie Duco, RN; Helen Fry, MA; Peggy Lavin, LCSW; Genie Skypek, PhD; Merlin Wessels, MSW, LCSW, ACSW; David Wadner, PhD Joint Commission Resources Mission The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject to change. Please also note that some of the examples in this publication are specific to the laws and regulations of the locality of the facility. The information and examples in this publication are provided with the understanding that the publisher is not engaged in providing medical, legal, or other professional advice. If any such assistance is desired, the services of a competent professional person should be sought. © 2013 The Joint Commission Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the USA 5 4 3 2 1 Requests for permission to make copies of any part of this work should be mailed to Permissions Editor Department of Publications and Education Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 [email protected] ISBN: 978-1-59940-706-7 Library of Congress Control Number: 2012950205 For more information about Joint Commission Resources, please visit http://www.jcrinc.com.

Contents Introduction ......................................................................................v Section 1: Basic Documentation Components ................................1 The Basic Elements of Care, Treatment, and Services ................................................1 Documentation for Core Processes of Care, Treatment, or Services ..........................4 Documentation for Support Processes........................................................................13 Implications of Electronic Health Care Records ..........................................................16 Ensuring Quality ..........................................................................................................21

Section 2: Screening and Assessment ..........................................23 Good Documentation for Screening and Assessment ................................................23 Analysis of Assessment Data ......................................................................................54 Precise Language for Written and Oral Communication ............................................56 Keeping Forms Viable ................................................................................................58 Laying the Foundation ................................................................................................73

Section 3: Planning and Delivery of Care, Treatment, or Services ....................................................................................79 Documenting the Plan of Care, Treatment, or Services..............................................81 Documenting the Delivery of Care, Treatment, or Services ........................................94 Defining Competencies for Documentation ..............................................................112 Managing the Need for Changes in Documentation Processes................................117 Summary....................................................................................................................117

Appendix: Joint Commission Standards Relevant to Documentation from the 2013 Comprehensive Accreditation Manual for Behavioral Health Care ............................................121 Glossary ........................................................................................141 Index ..............................................................................................153 iii

Introduction

D

ocumentation affects nearly every aspect of the delivery of care, treatment, or services in behavioral health care organizations. Screening and assessment information is used to guide interactions with the individuals served; plans of care, treatment, or services provide a means of communication among clinicians, staff, individuals served, and their families; assessments, plans, and progress notes justify interventions for third-party payers; performance measurement data help organizations identify potential problems in processes and outcomes; maintenance schedules and inventories allow organizations to track supplies and equipment used in various programs to ensure availability and safety; and specific documentation in many areas is required to meet regulatory and accreditation requirements. The list goes on and on. The need for accurate and timely documentation—whether in clinical/case records or in support functions—is nothing new to behavioral health care professionals, but the constantly changing environment of the behavioral health care field presents new opportunities and challenges to ongoing efforts to meet that need.

Keeping Up with Technology Over the past few years, various health care settings across the continuum have begun the changeover to electronic health records (EHRs). This switch is at least partially due to the more than $19 billion that the American Recovery and Reinvestment Act of 2009 provided in incentive payments to organizations that adopt health information technology (HIT). There are, of course, many benefits to computerized documentation. Inter- and intraorganizational communication among caregivers can be enhanced by access to real-time records and results. Care and/or services can be streamlined to improve efficiency, such as reducing repetition in taking histories and collecting assessment data. The safety and quality of care, treatment, or services can also be improved with software that warns prescribers about contraindicated medications and that includes prompts for evidence-based practices in planning of care, treatment, or services. On the financial side, staff can collect data for billing, performance improvement, and budgetary planning far more quickly and easily. Unfortunately, many behavioral health care organizations have been unable to adopt electronic systems for a variety of reasons, most comonly financial considerations. In a 2012 survey of 500 community mental health and addiction treatment organizations, 30% of respondents said that upfront costs were the primary reason they had not been able to implement new systems, and 12% also cited ongoing maintenance costs.1 This comes as no surprise, given that behavioral health care organizations were not eligible to receive the federal incentive payments available to other health care settings under the 2009 act.

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Other barriers have also been identified. For example, until recently, behavioral health care has not been represented in the development of national HIT standards, resulting in software being geared toward other settings. An electronic clinical/case record requires flexibility so that it can be used by medical and nonmedical personnel in both traditional and nontraditional settings, and for individuals who may require an array of services over an extended length of time—perhaps years.2 The issue of privacy is a critical one for individuals served by behavioral health care organizations because of the perceived stigma attached to many diagnoses of mental illness, substance use disorders, and so on; there is a fear of losing careers, insurance, and even relationships if confidential information is electronically available. Because individuals who need behavioral health care may also need the services of many different kinds of agencies and personnel (including welfare, corrections, education, juvenile justice, law enforcement, and employment assistance), the question of access to and security of information becomes even more complex.2 Behavioral health care organizations have to deal with stricter privacy requirements than do other health care settings. For example, federal regulations established under the Health Information Portability and Accountability Act (HIPAA) of 1996, the Federal Confidentiality of Alcohol and Drug Abuse Patient Records Regulation Act (42 CFR Part 2), and the Family Educational Rights and Privacy Act of 1974 require signed consent from the individual served (or a parent/guardian) before information such as psychotherapy notes, substance use treatment plans, and student educational and health records can be released.2 The good news is that the lack of resources behavioral health care organizations face is slowly being recognized and addressed. In 2011, the Behavioral Health Information Technology Act was introduced in Congress. The act is intended to amend the Public Health Services Act and the Social Security Act to make behavioral health, mental health, and substance use professionals and facilities eligible for HIT assistance.3 One of the eight strategic initiatives of the Substance Abuse and Mental Health Services Administration (SAMHSA) for 2012 was ensuring that behavioral health systems are able to participate fully in the adoption of HIT and interoperable EHRs.4 Individual states have developed initiatives to make standardized, regulation-compliant, and integrated electronic clinical/case record forms available online for outpatient services; the two current programs are the New York State Clinical Records Initiative and the Massachusetts Standardized Documentation Project.

Changing Focus: Person-Centered Care Traditional systems of care, treatment, or services have focused on the importance (or value) of the delivery process, identification of pathologies with the aim of decreasing symptoms, compliance with regulations and requirements from outside entities, and detection of deficits that need to be fixed. However, this focus is shifting to a model that focuses on achieving outcomes for the individual served, improving that individual’s quality of life, working toward the individual’s personal goals, and building on his or her strengths.5 This new model is known as person-centered care, and it appropriately makes the individual served the heart of the process.

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To the greatest extent possible, the individual is made a “senior” partner in all planning for and delivery of his or her care, treatment, and services. He or she attends planning meetings, is offered a copy of the final plan, and receives education about the care/treatment/service process and what to expect. Person-centered care recognizes that people besides the individual served (such as parents, spouses, significant others, children, and friends) may contribute to the process and promotes that involvement. Each individual served has unique goals, needs, strengths, and preferences, and these are identified and built into the plan of care, treatment, or services. Instead of looking for what’s wrong with the individual, clinicians emphasize existing strengths and help the individual served build on or add to them in order to achieve his or her goals. Person-centered care, treatment, or services encourages individuals served to invest in their own recovery. It also encourages behavioral health care professionals to look at documentation in a new way. Documenting assessments, plans, and progress notes becomes a “value-added” activity that helps the individual served move toward his or her goals. With the individual actively participating in each step of care, treatment, or services, each document becomes necessary. Assessments become learning opportunities, where individuals figure out what they really want and that they have strengths they can build on to achieve their goals. Recovery plans describe the necessary steps to getting what they want. Evaluations of ongoing progress let both the individuals served and professionals determine whether the planned steps are having the desired effect and helping the individuals move toward their goals.5 Seeing documentation in this light makes it much more than an unrewarding chore.

Promoting Recovery for Adult Populations A large part of person-centered care is promoting the recovery of the individual served. Recovery has been defined in many different ways, but it basically refers to a personal process of change in which people with mental health and addiction issues improve their quality of life. Person-centered or recovery-oriented systems recognize that individuals with complex mental health issues want the same things from life that other people do: meaningful activity, a safe place to live, and connections with others. Recovery does not always mean that the individual served no longer has a mental illness or addiction; it means that he or she has consciously decided to pursue a process of healing that allows him or her to thrive rather than just survive. The US Health Department’s SAMHSA has defined a number of guiding principles for recovery, including the following6: • It is holistic, self-directed, and empowering. • It is supported by peers and involves (re)joining and (re)building a life in the community. • It involves a process of self-redefinition, addresses discrimination, and transcends shame and stigma. • It includes cultural dimensions. Many organizations, agencies, and other entities are promoting recovery-oriented care systems. For example, the Ohio Department of Mental Health developed a Recovery Process Model and Emerging Best Practices program to educate individuals about their role in the recovery process and in advocating for high-quality care, treatment, or services. The best practices booklet that has been developed as part of the program can be used as an educational tool for mental health professionals, families, regulators, and third-party payers.7

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With the recovery model’s emphasis on community support, accurate and complete documentation becomes even more important. Individuals served often depend on a variety of agencies and programs—such as education, housing, and public benefits—as well as different behavioral health care settings to help establish quality of life. Documentation is the key to facilitating communication among all these entities.

Emphasizing Resilience in Children and Youth Populations Statistics show that more than 1.5 million children and adolescents were involved in the juvenile justice system in 2009,8 and more than 400,000 children were in foster care in 2010.9 These populations have often been exposed to a wide range of traumatic events, including violence at home or in their community, physical or sexual abuse, economic hardship, loss of family and/or friends, and life-threatening injuries or illness. Such traumas leave marks both emotionally and physically. The child or youth may become hypervigilant about perceived threats, avoid expressions of emotion, experience fragmented and chaotic memories, underachieve in school, and be unable to form close relationships with others. Thus, promoting resilience becomes a high priority for behavioral health care organizations that serve children and youth who have experienced trauma. Resilience is the ability of an individual to cope with adversity and change. It is characterized by the capacity to make and carry out realistic plans, good communication and problem-solving skills, an optimistic view of life, confidence in personal strengths and abilities, and the ability to manage strong emotions and impulses.10 No one knows exactly why some individuals are able to bounce back from adversity better than others with similar experiences, but helping children and youth develop that ability is vital. Various programs and initiatives have been established to help with these endeavors. For example, the Sanctuary Model® was developed to help organizations create a collaborative, healing environment to improve the effectiveness of treatment for traumatized individuals, to reduce the use of restraints and other coercive practices, and to build cross-functional teams. It is intended to be used in residential treatment settings for children, public schools, domestic violence and homeless shelters, group homes, outpatient and community-based settings, juvenile justice and substance abuse programs, parenting support programs, acute care settings, and other programs aimed at assisting children.11 SAMHSA’s National Child Traumatic Stress Initiative is a federal grant program aimed at providing and improving access to trauma-focused treatment for children, adolescents, and families. In research, studies have been conducted on the effectiveness of Multidimensional Treatment Foster Care (MTFC) in promoting resilience in foster care populations.12 MTFC programs involve multiple settings and include school-based behavioral interventions and academic support, skills training for youth, psychiatric consultation and medication management (when necessary), training and support for foster parents, and family therapy for biological parents. Documentation can support an organization’s focus on resiliency. Trauma-informed assessments and plans of care, treatment, or services address the specific goals, needs, strengths, and preferences of children or youth with traumatic pasts who are being treated for co-occurring conditions.

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Integrating Physical Care into Behavioral Health Care Adults who have had any mental illness or a major depressive episode in the previous year are more likely than adults without these illnesses to have asthma, diabetes, heart disease, high blood pressure, and strokes. Similar statistics are true for adults who have had serious mental illness; these individuals are more prone to have asthma, high blood pressure, and strokes.13 In addition, adults with serious mental illness generally die 25 years earlier than other Americans, due to treatable medical conditions.14 There is no doubt about the need to integrate primary care services into behavioral health care settings. The question is how to meet this need. A few models exist. One is the health home, or person-centered health care home; most community behavioral health centers fall into this category. These homes integrate behavioral and primary health care by offering and facilitating access to social services and behavioral, physical, and long term care. The professionals from different disciplines may all be in-house or outside contractors. The Ohio Medicaid Health Home program, which launched in October 2012, is establishing health homes within the state for adults on Medicaid who have serious and persistent mental illness or serious mental illness and child welfare agencies for children with serious emotional disturbances. Each home will have a team to coordinate the care of individuals served, including a health home team leader, a care manager, an embedded physical health primary care clinician, and qualified health home specialists. Goals include increasing the population’s use of prevention and wellness services, reducing hospital admissions and readmissions, and reducing the use of hospital emergency departments.15 Another model involves the direct provision of physical care through an organization. Medical nurse practitioners or primary care physicians are available at specific times to offer routine services, such as checking lipid and glucose levels, blood pressure, and weight/body mass index. Seeing these clinicians in a familiar setting, possibly accompanied by behavioral health care staff he or she knows, can make the individual served more comfortable with and amenable to receiving physical screenings and care. Also, the organization can ensure that clinicians who come in to provide services are familiar with the needs and health risks of individuals receiving care, treatment, or services. A third model is one in which the behavioral health care organization has a formal arrangement with other providers to see individuals served. Depending on an individual’s mental health status, this may not be as effective as the other two models because he or she may resist seeking physical care and/or may not wish to be treated by a stranger. The organization may lease space within its facility to a physician or other practitioner to provide physical care to the individuals served. The physician or other practitioner does not work for the organization, but individuals can receive care in this familiar setting. Alternatively, if a physician’s office is nearby, a staff member may go with the individual served and introduce him or her to the physician to help establish a rapport between them. In some cases, an organization may take mental and primary physical health care services directly to the individuals served. For example, among the programs administered by Heartland Alliance—a Chicago-based international organization that helps people obtain the basic needs of housing, health care, employment, and legal help—are comprehensive physical health care services for homeless individuals. These services include mental health and substance use treatment, primary care, and

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dental care. Teams of health care professionals meet individuals in shelters, in single-room occupancy buildings, on the street, and at Heartland’s health centers throughout Chicago.16 Again, documentation plays an essential role in facilitating communication among the various clinicians and health care professionals involved in an individual’s care, treatment, and services. Assessments and plans need to reflect the integration of each individual’s goals, needs, strengths, and preferences for both behavioral and physical health.

What This Book Offers A Practical Guide to Documentation for Behavioral Health Care, fourth edition, is an update of a popular publication that focuses on helping staff at all levels effectively prepare and use documentation that supports safe, high-quality care, treatment, and services, as well as support processes. The examples included in this book illustrate ways in which a variety of behavioral health care organizations have successfully documented assessments; plans of care, treatment, or services; and various processes such as medication reconciliation, progress notes, and resource allocation and maintenance. This publication is divided into the following three sections: • Section 1, “Basic Documentation Components,” discusses the continuous process of data collection, data assessment, action planning, and action implementation; the need for good documentation of the core processes of care, treatment, or services; documentation associated with support functions such as reimbursement; and the implications of electronic records. It also outlines The Joint Commission’s documentation requirements for care, treatment, or services. • Section 2, “Screening and Assessment,” discusses components such as physical, emotional and behavioral, spiritual, and cultural assessments. It also addresses the analysis of the significant data gathered from various screenings/assessments into a single evaluation and the importance of precise language. • Section 3, “Planning and Delivering of Care, Treatment, or Services,” discusses aspects of the plan for care, treatment, or service; plan reviews; progress notes; documentation of interventions; and practice guidelines. In addition, this section looks at defining competencies for documentation and managing necessary, ongoing changes to documents. The forms shown throughout all three sections are included on the accompanying CD. You can use the forms on the CD as a starting point for creating and/or revising documents that meet the specific needs of your setting and scope of care, treatment, or services. Remember that the examples and tools shown may not be applicable to every behavioral health care organization.

New in the Fourth Edition Here are some highlights of this new edition: • Electronic records. It does not matter whether your organization uses a paper or an electronic format for documentation, as long it meets your needs. However, in recognition of the growing use of HIT, the discussion of electronic records in Section 1 has been expanded, and more of the examples throughout the book come from electronic systems.

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• Current standards and regulations. Discussions of regulatory and accreditation requirements for various types of documentation have been updated to reflect current regulations and standards. • Relevant documentation requirements. A new appendix provides The Joint Commission standards and elements of performance for the documentation of care, treatment, and services for easy reference. • Updated example tools and forms. Due to length constraints, some of the book’s examples of documentation actually used in hospitals have been excerpted to show only specific sections. However, the complete forms are provided on the accompanying interactive CD. The CD also includes different versions of some of the forms. For example, if the book shows an example of an assessment for adults and the organization also has a different version of the same form for children/adolescents, both versions are given on the CD. • New planning form exercises. The CD includes four case examples to help you improve your skills in documenting the needs, strengths, preferences, and goals of individuals served in order to develop an effective plan of care, treatment, or services. A blank planning form is provided for each case. Each of these forms can be filled in and then compared to a completed example, printed, and/or discussed as desired.

Terms Used in This Book The terminology used for care, treatment, and services—as well as those who receive them—varies across the wide variety of settings and facilities. For the sake of simplicity and clarity, this book refers to those who provide care in settings such as crisis stabilization, residential/group homes, transitional/supervised living, therapeutic foster care, foster care, corrections, forensics, day programs, family preservation/wraparound, case management, in-home, outpatient, vocational rehabilitation, shelters, online, outdoor, and opioid treatment programs simply as behavioral health care organizations. The exception is when a discussion refers to a specific type of program or setting. The person receiving care, treatment, or services may be a child, a youth, or an adult, so this book refers to all of them as individuals served. Again, there are exceptions. Descriptions of individuals receiving care at a specific kind of behavioral health care organization or quotations from specific people or forms from contributing organizations use the term appropriate to those organizations.

Acknowledgments Along with the surveyors and program staff at The Joint Commission who helped gather material for this book, we would like to thank the contacts at each organization who contributed examples: Laurie Holdener at Chestnut Health Systems in Bloomington, Illinois; Abigail Halloran Baldwin at Foundations Behavioral Health in Doylestown, Pennsylvania; Kathie Kostock at Lake County Health Department and Community Health Center’s Behavioral Health Service in Waukegan, Illinois; Mike Matoney at New Directions in Cleveland, Ohio; Nan Genther at NorthKey Community Care in Covington, Kentucky; Brian Pace at Red Rock Canyon School in St. George, Utah; Scott Kelly and Regina White at Summer Sky Treatment Center in Stephenville, Texas; Randy Hayes and Mark DeDenato at Timberline Knolls in Lemont, Illinois; and Barbara Guyton, Phyllis Yester, and Dennis Call at VisionQuest in Downington, Pennsylvania.

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References 1.

2. 3. 4. 5. 6.

7. 8. 9. 10. 11. 12. 13.

14.

15. 16.

National Council for Community Behavioral Healthcare: HIT Adoption and Readiness for Meaningful Use in Community Behavioral Health. Jun 2012. Accessed Jul 5, 2012. http://www.thenationalcouncil.org/galleries /business-practice%20files/HIT%20Survey%20Full%20Report.pdf. Phillips J. Behavioral Health Electronic Medical Records: Unique Implementation and Privacy Challenges. Feb 5, 2010. Accessed Jul 5, 2012. http://www.mahealthdata.org/resources/Documents/Jaffy_Final_2.5.10.pdf. S.539: Behavioral Health Information Technology Act of 2011. Accessed Jul 9, 2012. http://www.govtrack.us/congress/bills/112/s539. Department of Health and Human Services: Justification of Estimates for Appropriations Committees, Fiscal Year 2012. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. Skypek G. Changing Your Thinking About Clinical Documentation. Dec 2011. Provided by the author. (Originally published at http://www.netsmartuniversity.com). Department of Health and Human Services: Guiding Principles and Elements of Recovery-Oriented Systems of Care: What Do We Know from the Research? Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009. Ohio Department of Health. Overview of Emerging Best Practices. Accessed Jul 9, 2012. http://www.mhrecovery.com/overview.htm. US Department of Justice, Office of Juvenile Justice and Delinquency Prevention. Juvenile Court Statistics: 1985–2009. Statistical Briefing Book. Accessed Jul 9, 2012. http://ojjdp.gov/ojstatbb/ezajcs/asp/demo.asp. Children’s Bureau/ACYF. Foster Care Statistics 2010. Accessed Jul 9, 2012. http://www.childwelfare.gov/pubs/factsheets/foster.pdf. American Psychological Association. The Road to Resilience. Accessed Jul 10, 2012. http://www.apa.org/helpcenter/road-resilience.aspx#. The Sanctuary Model®. Accessed Jul 10, 2012. http://www.sanctuaryweb.com. Leve LD, Fisher PA, and Chamberlain P. Multidimensional treatment foster care as a preventive intervention to promote resiliency among youth in the child welfare system. J Pers, Dec;77(6):1869–1902. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The NSDUH Report: Physical Health Conditions among Adults with Mental Illnesses. Apr 5, 2012. Accessed Jul 10, 2012. http://www.samhsa.gov/data/2k12/NSDUH103/SR103AdultsAMI2012.pdf. National Alliance on Mental Illness. Mental Illness: Facts and Numbers. Accessed Jul 10, 2012. http://www.nami.org/Template.cfm?Section=About_Mental_Illness&Template=/ContentManagement /ContentDisplay.cfm&ContentID=53155. The Joint Commission. Ohio to create health homes for individuals with SPMI/SMI/SED. BHC News, Issue 2, 2012. Accessed Jul 9, 2012. http://www.jointcommission.org/assets/1/18/BHC_News_2_2012.pdf. Heartland Alliance for Human Needs & Human Rights. Health Care. Accessed Jul 10, 2012. http://www.heartlandalliance.org/whatwedo/our-programs/health-care.

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C

are, treatment, and services represent an integrated system of processes and outcomes. This system is composed of four basic elements: data collection, data screening/assessment, action planning, and action implementation (see Figure 1-1, page 2). The system is not a sequence of independent events but a continuum. Organization* policies and procedures give the system structure and guiding principles. The structure is designed to achieve specific outcomes, but it has built-in flexibility so it can be tailored to different models of care and different types of users.

The Basic Elements of Care, Treatment, and Services The core process of care, treatment, or services generally involves the continuous interaction of specific components in the same sequence. However, refinements are common, and some elements may be revisited repeatedly, as warranted by an organization’s population(s) and scope of services. An abbreviated description of the steps follows.

Data Collection Data collection includes the screening, assessment, history taking, testing, examination, observation, and interviewing steps in the process. Staff collect data on the past and current physical, emotional, and behavioral functioning of the individual served, as well as his or her needs, strengths, preferences, and goals. In most instances, behavioral health professionals within the program or service collect this information. When specialty testing or examinations are required, they may be performed by external providers who have been deemed competent by the organization’s clinical/service and administrative leadership. The process of gathering initial information marks the beginning of the care, treatment, or services process and constitutes the time the individual served is engaged in that process. It may be initiated on site with a staff member or by intake staff over the phone. Data are gathered as quickly as possible so that the other activities in the process can be initiated without delay.

Data Assessment After data have been collected, they are assessed (that is, evaluated). It is important to note the difference between collecting data and evaluating data. Assessment means evaluating data thoroughly and drawing conclusions about the impact of the data on the individual served. This is much more extensive than merely gathering information.

* Throughout this book, the term organization is used to include provider, agency, and so on.

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A Practical Guide to Documentation in Behavioral Health Care, Fourth Edition

Figure 1-1. Core Process of Care, Treatment, or Services Data Collection Behavioral/Emotional FunctioningExamination-Screening-Testing (Observation-Interviewing Responses) Action Implementation Identifying Goals/Outcomes (Implementing Planned Responses)

Individual Served

Screening/ Data Assessment (Evaluation)

Action Planning (Establishing Responses) The process of care, treatment, or services in behavioral health care involves four main elements that form an ongoing cycle for the purpose of helping the individual served achieve his or her desired personal outcomes (goals).

A professional assessment focuses on the individual served. Clinicians and staff strive to understand the individual’s behavior and what causes it, but they do not judge his or her underlying character. Furthermore, clinical/service assessments focus on how behavior creates difficulty or is a source of strength for the individual served rather than on how it affects those gathering the information or others. At the more intense levels of care, treatment, or services (such as crisis stabilization units in community mental health centers, residential programs, and day treatment programs), individuals served are usually evaluated by a variety of professionals with expertise in one of the physical, psychological, or social dimensions. For example, nurses and physicians apply their special knowledge and skills to evaluate the physical dimension; psychologists, psychiatrists, clinical social workers, and mental health counselors focus on the mental health dimension; and social workers, counselors, rehabilitation specialists, and others with specialized expertise assess the behavioral functions.

Action Planning Using the information obtained through analysis of significant data from screenings/assessments, observation, interviews, and so on, and with the collaboration of the individual served, the clinician or team does three things: It (1) identifies the individual’s needs, strengths, preferences, and goals; (2) prioritizes the needs and goals; and (3) formulates a plan of action in a written plan of care, treatment, or services. As additional data are gathered, more observations are made, and further assessments are completed, the new information is used to supplement the initial plan.

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When an organization uses a multidisciplinary approach and holds the first formal session for planning care, treatment, or services, the multidisciplinary team should review any existing plan that has been activated (for example, an initial plan that may have been prepared by the intake clinician). The team should evaluate unachieved goals and unmet needs, and it should include those requiring continued attention in the plan it is developing. The team should review the plan of care, treatment, or services on a regular basis, as specified by the organization’s policies and procedures, and whenever any significant change in the condition of the individual served may require a revision to the plan. The individual served should be involved in developing his or her plan of care, treatment, or services. Active participation is critical. It helps ensure that the plan addresses the individual’s specific needs and that he or she is invested in the outcomes of care, treatment, or services. Lack of participation can result in low levels of motivation and buy-in, meaning the individual served is less likely to cooperate with the planned activities and interventions and more likely to drop out of care, treatment, or services. Engagement can be accomplished in a number of ways. In some instances, the individual served may sit in on and contribute to the multidisciplinary planning session. In other situations, staff may work with the individual before (never after) the team session. Whatever the method, the individual served should know what the plan’s goals and objectives are and understand why they were established, what they mean, and how they will be achieved. It is not enough to simply have the individual served sign off on the plan of care, treatment, or services without any other involvement in the process. His or her participation can easily be reflected in a descriptive progress note similar to the following: Maria actively participated in planning her care, treatment, or services by stating her goals and by providing feedback to staff on her needs, strengths, and preferences. She is “good with numbers and likes detail work.” She has established a short-term objective of doing volunteer work at the local library and eventually would like to be employed and live in an apartment. Maria understands and agrees that her participation in a 12-step program and individual counseling sessions are necessary steps toward her long-term goal of employment and living independently. She does not agree with the anger management goal. She does not see anger as an issue or barrier in reaching her goals. Maria and her counselor, Brian Wells, will discuss this issue during individual sessions to further assess whether anger may be a barrier. Maria agreed to this approach.

This note shows that the individual served has helped to develop the plan, understands its goals, and agrees or disagrees with various aspects of the proposed care, treatment, or services.

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Action Implementation An organization should deliver the activities and interventions identified in the plan of care, treatment, or services according to the time period documented in the plan. Occasionally, the individual served may be given reading, writing, or other assignments to help bring about behavioral change. A monitoring mechanism is needed to ensure that these assignments are completed because they are considered planned interventions. As a routine part of their responsibilities, staff should continuously evaluate the effectiveness of the interventions/services/special behavioral procedures and determine whether the frequency, type, or intensity should be modified. The scope of the review is particularly important if the individual served does not appear to be achieving objectives or goals. The review should always include a determination of whether the interventions/services/special behavioral procedures were actually carried out as detailed in the written plan. The review and evaluation of progress begins the entire data collection and assessment part of the cycle over again.

The written guidelines and standards of licensing agencies, payers, and regulatory bodies often divide the care, treatment, or service process into distinct subprocesses, such as screening/assessment; planning of care, treatment, or services; and delivery of services. They may evaluate them separately, although The Joint Commission does not view these processes as isolated steps. An unintended outcome of this division can be the erroneous impression that each is a singular event in relationship to the other steps in the care, treatment, or service process. In reality, each is merely a checkpoint to track whether objectives and goals are being achieved. The administrative separation of the care process into individual parts is necessary and reasonable when you are trying to respond effectively to the demands of managed care entities, third-party payers, and external review agencies. Moreover, conducting evaluations at these defined points can improve the efficiency of vital organization functions, such as performance improvement, quality control, risk management, information management, and usage review. Information from these evaluations can also be used in peer review, staff development, or performance appraisal (including competency assessment) activities. Unfortunately, staff may reach the false conclusion that when the required steps in the process have been completed, the quality of subsequent documentation is less important. This may partially explain why staff sometimes perceive assessment summaries; planning of care, treatment, or service sessions; and discharge planning reviews as agonizing but necessary events rather than as important checkpoints for outcome achievement within a continuous process.

Documentation for Core Processes of Care, Treatment, or Services Regardless of the type or level of care, treatment, or service an individual receives, the structure of care, treatment, or service encompasses at least the following steps: 1. Initial screening/admission/assessment 4

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2. 3. 4. 5. 6. 7.

Physical health status and emotional/behavioral assessment Analysis of data and assessments and prioritization of the needs of the individual served Planning of care, treatment, and services and review/update of that plan Implementation of interventions/services Identification of the individual’s strengths, preferences, and goals Discharge/transfer planning, if applicable

Each of these steps requires accurate, timely documentation. Such documentation is important on many levels. First, it forms the basis for decisions about whether to provide care, treatment, or services and, if so, which care, treatment, or services and at what levels are most appropriate. Effective documentation records all relevant data for the care, treatment, or services of the individual served, including which interventions/services work and which do not. It also provides a means of ongoing communication between the individual and staff. Second, documentation justifies the need for care, treatment, or services and confirms that treatment was carried out according to an approved plan. This justification is important for receiving reimbursement from third-party payers, demonstrating compliance with regulatory and accreditation requirements, and providing legal protection to the organization. Third, documentation that captures necessary data can be used to measure both general process and individual treatment outcomes by making it easier to track specific indicators consistently over time. The descriptions given in this section provide an overview of documentation in the care, treatment, or service process as a whole. Each stage is explained in detail in Sections 2 and 3.

Initial Screening The process of care, treatment, or services begins with the first contact between the organization and the individual served.* At this initial contact, a staff member needs to gather sufficient preliminary data on strengths, preferences, and goals to determine what clinician/health care professional, program/service, setting, and level of care, treatment, or services are appropriate for that individual’s needs and goals. These data, all of which must be documented, include the following: • Behavioral and emotional needs/conditions that relate to the reason(s) the individual served is seeking or has been referred for care, treatment, or services • A physical health screening • The presence, duration, and acuity of physical pain • Nutritional, educational, vocational, and legal status, as relevant Each organization has criteria for determining whether individuals are eligible for its care, treatment, or services. The information obtained at the initial screening allows an organization to evaluate whether its care, treatment, or services are appropriate to the individual’s needs, preferences, and * Although the text focuses on interactions with the actual individual served, the participation of family members and significant others is often encouraged and helpful at each step of the care, treatment, or services process, including assessment screening. When the individual served is a minor, the participation of a parent or guardian is required.

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goals or whether that individual should be referred to another provider or setting. If the evaluation reveals that the individual is appropriate for care and that the required services are available and accessible, the next step in the process (assessment) can be planned and implemented. Initial encounters between the individual served and the organization can occur in a variety of ways. For example, trained staff (that is, a screening staff member or secretary) may gather some initial data on the individual, whether in person or over the telephone. This is usually restricted to data for identification but may also include some clinical data, which are often limited to the source of and reason for referral. This type of data collection does not flow into data screening/assessment, with perhaps one exception: age. For example, if a program has defined the population(s) that will be admitted and treated as being limited to adults ages 18 to 64, a 16-year-old presenting may be considered inappropriate for admission due to her or his age. However, collection and assessment of the data pertaining to the youth’s immediate needs may lead the organization to admit and treat him or her despite the age discrepancy. Instead of having contact with screening staff, an individual may come into a program/service and provide required data by completing assessment forms, questionnaires, tests, and/or other evaluations, as well as providing information about processes such as legal proceedings and court referrals. In this type of screening, data collection does not flow into data assessment. The actual assessment of the data and the decision to provide care, treatment, or services take place at a later time or at a different location. Finally, an individual may meet directly with a clinician who collects and assesses data to determine the appropriateness of the organization providing care, treatment, or services to this individual. Of all screening processes, data assessment is most comprehensive during this type of screening. It is based on the actual data as well as on the individual’s presentation, including eye contact, tone and level of voice, and demeanor. The clinician uses all this information in the assessment process. Once a provider determines that an individual’s condition meets the program’s documented intake/admission criteria, staff may gather and assess more specific data and initiate a plan of action for care, treatment, or services. (See Sidebar 1-1 on page 7 featuring one organization’s approach to successfully improving its intake screening process.)

Physical Screening and Assessment An organization must assess an individual’s physical function in order to develop an effective plan of care, treatment, or services. The physical examination or screening protects the individual from physical health conditions that may be concealed because of behavioral health issues and determines whether a physical condition is contributing to the behavioral health issues or vice versa. The timing and purpose of the physical assessment varies by setting, and both the date and findings must be included in the clinical/case record.

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Sidebar 1-1. Streamlining the Intake Process and Documentation Many organizations/agencies struggle to conduct intake screening sessions in a timely manner. Two of the complicating factors are the amount of documentation that needs to be done and the length of time needed to complete it. NorthKey Community Care, with a network of 18 facilities throughout Kentucky, revised both its intake forms and its process to address this problem. NorthKey—which provides services to those with mental health issues, substance use disorders, and intellectual disabilities—had a history of long wait times (three to six weeks) for first appointments and a high rate of no-shows for both first and second appointments. NorthKey had tried a variety of solutions—including a triage model in which clients were double-booked in anticipation of a 45% to 50% no-show rate—without any quantifiable success. In 2009, a dedicated team that included the director for adult services, the coordinator of one of the adult units, the coordinator of adult crisis services, the client records director, the vice president of outpatient services (for support and consultation), and a representative from the quality improvement staff (for consultation on paperwork) began to work on a new process to address the problem. “There was a lengthy paperwork process for the first session,” recalls Nan Genther, NorthKey’s director of quality improvement. “The client was given a multipage self-report biopsychosocial form in the waiting room that took a long time to complete. Then the clinician took a clinical history in the screening session.” All clients were automatically scheduled for a second session if the clinician completed the second part of the clinical assessment and determined whether the client was a good fit for NorthKey’s services. According to Genther, “The team surmised that we were trying to get too much history at the first contact and that we should focus on the presenting problem, a risk assessment, a mini-mental status, and formulation of a working diagnosis.” A new initial assessment form was drafted to cover these points, and one adult unit volunteered to pilot test it. Clients were scheduled into the unit for 30-minute intake appointments and the clinicians completed the new form, evaluating each client for readiness to change and his or her appropriateness for outpatient therapy. If a client was considered appropriate for ongoing treatment, he or she was given the self-report biopsychosocial form to complete at home and then invited to call the next day to schedule a second session. “Based on the clinician’s initial assessment, he or she recommends that the client call back for a second appointment, and that call-back demonstrates the client’s commitment,” explains Genther. “Of course, all of this depends on the acuity and level of impairment the person is (continued)

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Sidebar 1-1. Streamlining the Intake Process and Documentation experiencing. If he or she has a severe mental illness or is significantly impaired, we automatically reschedule them.” Both the initial assessment and biosychosocial forms can be found on the CD that accompanies this book. The new process and documents reduced wait times in the pilot unit by one to two weeks, and it was rolled out to all the other outpatient units by the end of 2010. Each unit schedules intake appointments one day a week, either morning or afternoon, and the process can be tailored to the individual site. Each unit chooses its own time, and one even has rapid intake periods twice a week to keep up with demand. According to NorthKey’s quality improvement data, the percentage of callers who were scheduled for an initial appointment within 14 days was 39 percent in 2009, 59 percent in 2010, and 87 percent in 2011. Many units currently have wait times of only a few days.

Behavioral and Emotional Assessment The behavioral and emotional assessment focuses on the past and current behaviors, emotional functioning, needs, strengths, preferences, and short- and long-term goals of the individual served. Depending on the setting/services/programs involved, the organization may screen for addictive behaviors, mental status, the need for psychological and psychiatric services, and/or intellectual and cognitive functioning. When treating children and youth, organizations must also collect data on the individual’s legal status and guardianship, family dynamics, current living situation, and family history. In addition, an organization must consider a child’s/youth’s level of emotional, cognitive, educational, nutritional, and social development.

Screening for Risk of Harm to Self or Others and Abuse/Trauma All behavioral health care programs must screen individuals on admission for any risk of immediate harm to the individual served or others. Such a risk calls for immediate intervention rather than waiting for standard assessment and planning activities. For example, Lake County Health Department and Community Health Center Behavioral Health Services ensures that risk assessments for suicide/self-injury and violence/homicide are on the first page of its interview form for crisis services (see Figure 1-2, pages 9 and 10).

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Figure 1-2. Crisis Interview Form

This form ensures that individuals being screened for crisis services are evaluated for possible harmful behavior toward themselves or others.

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Figure 1-2. Crisis Interview Form, continued

Source: Lake County Health Department and Community Health Center Behavioral Health Services, Waukegan, Illinois. Used with permission.

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Another part of the screening process for all settings is the identification of individuals who are suffering or may have suffered abuse, neglect, trauma, or exploitation. Because the effects of these events can affect behavior immediately or long after they occur, it is important to include such experiences in the assessment and planning for care, treatment, and services. Note that the term trauma includes a wide variety of life events that adversely affect an individual’s functioning, such as a child experiencing the death of a parent. Thus, organizations must report only the specific traumas of abuse, neglect, and exploitation to authorities (as required by laws and regulations).

Analysis of Data and Prioritization of Needs Once all the data are gathered and the assessments are reviewed, clinicians and other behavioral health professionals analyze this information to determine an individual’s most immediate needs for care, treatment, or services. For example, treatment for the physical repercussions of substance abuse or an eating disorder may take precedence for a new arrival; this may include getting the individual to comply with necessary physical medical treatment. This documented analysis of the assessments and prioritization of the individual’s needs leads directly to the process of planning for care, treatment, or services.

Planning for Care, Treatment, or Services A behavioral health professional or a multidisciplinary team creates a written plan of care, treatment, or service based on the analysis of the physical and emotional/behavioral assessments in conjunction with the needs, strengths, preferences, and goals of the individual served and the identified priorities. The individual’s and/or family’s participation in the development of the plan is vital to its success. The plan must identify goals for care, treatment, or service interventions that will be used to meet those goals; methods for evaluating the progress of the individual served; and the level of participation expected from the individual’s family. Because individuals served are constantly being reassessed, the plan of care, treatment, or services also needs to be reviewed and updated periodically. Most organizations have a set schedule for review, such as once every two weeks, monthly, or twice a year, depending on the condition(s) of the individual served and the programs/services provided. However, revisions may also occur when there is a change in the individual’s condition or he or she is failing to progress according to his or her own evaluation and/or that of the provider.

Implementation of Interventions Staff must document all the interventions provided to the individual served, as well as his or her response to the interventions, in the clinical/case record. This is especially important when several disciplines or settings are involved because effective coordination of care, treatment, and services depends on good communication and shared knowledge among staff. The following are some examples of steps and plans that would be recorded: • Nutritional counseling and education in oral health for individuals with eating disorders • Participation in social and community situations for individuals with intellectual and developmental disabilities

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• Provision of age-appropriate education for children or youth whose care, treatment, or services require a prolonged absence from school • Medication(s) administrated and reconciled logs for drugs prescribed in a methadone maintenance program Observations of the individuals served during these interventions and their progress should inform the plans for discharge, follow-up care, or transfer to a different setting, if applicable.

Discharge Planning Good documentation is essential to maintaining continuity of care, treatment, or services when individuals are transferred from one setting to another or when they are discharged back to the community. As with the original plan of care, treatment, or services, the discharge/transfer plan is based on the individual’s needs, preferences, goals, and physical and emotional/behavioral status. The plan should include at least the following information: • The reason for discharge/transfer • The anticipated need for continuing care, treatment, or services after discharge/transfer • The individual’s emotional/behavioral functioning status at the time of discharge/transfer • A summary of the care, treatment, or services that have been provided and the individual’s progress toward his or her goals • Referrals for community resources Organizations should offer specific discharge/transfer assistance depending on their population. For example, facilities that serve young adults who are trying to transition to independent living may help these individuals find jobs and housing, access community health care, and learn how to handle money. Addiction treatment programs should address relapse prevention with individuals to be discharged. Methadone maintenance programs should refer pregnant individuals for prenatal care.

Joint Commission Standards The expectation for documentation is implicit throughout The Joint Commission standards and requirements. The majority of specific documentation requirements, particularly as they relate to the process of care, treatment, or services, appear across three chapters of the Comprehensive Accreditation Manual for Behavioral Health Care: “Care, Treatment, and Services” (CTS), “Information Management” (IM), and “Record of Care, Treatment, and Services” (RC). Note that the relevant standards from these chapters are provided in the appendix to this book. Additional documentationrelated standards and requirements appear in the “National Patient Safety Goals” (NPSG), “Leadership” (LD), and “Performance Improvement” (PI) chapters. Although the standards undergo periodic revisions and updates, the requirements remain consistent in their aim of ensuring precise, well-planned, and accurate documentation for individuals served in order to promote the delivery of safe, effective, high-quality care, treatment, and services. Because documentation processes are carried out using myriad methods across various types of organizations, The Joint Commission does not mandate the use of a specific documentation format.

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How you choose to implement and document each step of the process should be specific to your organization and reflect its mission and values, population(s), physical environment(s), standards of practice, and staff. Even the names of the steps may vary. You may use a different term for the plan of care, treatment, or services, including treatment plan, individualized education plan, recovery plan, or foster care plan. Further, you may keep care records, clinical/case records, health care records, or patient/resident records. Again, the terms and format you use are of secondary importance to the processes and outcomes they record. Although third-party payers, licensing bodies, and accrediting agencies may influence the vocabulary and content of your documentation, they should not determine your name for a process or its scope. Remember to focus on the quality of your documentation rather than on how it is formatted. Health care records and other documents must, first and foremost, be functional for those who use them. Joint Commission standards emphasize using uniform data definitions and vocabulary within your individual organization and tailoring them to fit your needs. Once a form or document is functional, you can adapt it to meet the requirements of payers, regulators, and accreditors, if needed.

Documentation for Support Processes The use of effective documentation is not limited to the realm of clinical documentation. Support processes, such as those described in the following sections, keep the organization running and ensure that its programs are safe and effective. These processes also need documentation of data and actions taken for a variety of purposes.

Performance Measurement and Improvement The key elements of the performance improvement cycle mirror those shown in Figure 1-1 (on page 2) for the process of care, treatment, or services. Data on a specific process or outcome are gathered, the raw data results are assessed to identify problems or opportunities for improvement, actions to solve the problem or make the improvement are planned and then implemented, data are gathered on the effects of the actions taken, and the whole process begins again. Analysis of aggregated data in behavioral health care may reveal opportunities such as “missed areas of need” in the assessment of recidivist individuals served, lack of agreement between diagnoses/conditions and goals and/or interventions, ineffective referrals or linkage efforts, failure of individuals served to progress, or ineffective or inappropriate staff response to such failure. Take, for example, the efforts of a comprehensive mental health center. In a quality audit, staff randomly selected 30 clinical records to look at the quality and specificity of justification for diagnoses given. They found poor documented support for diagnoses in both psychiatric and biopsychosocial assessments. Diagnoses were often simply carried forward from other providers. The number of “rule-out” diagnoses that were never ruled out was high. In addition, this organization had recently moved toward a trauma-informed care perspective. Staff found the number of traumarelated diagnoses to be below the prevalence figures for the general population and significantly below the prevalence estimates for people with mental health and/or substance use issues.

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A representative clinical team was appointed to select a short-form standardized screening tool for use by both psychiatrists and biopsychosocial assessors in the diagnostic process. Since many short-form screening tools do not screen for posttraumatic stress disorder or whether symptoms might be trauma related, the team also included short-form tools for screening for trauma and trauma-related symptoms. A review of another 30 randomly selected clinical records three months after implementation of these screening tools found much greater support for diagnoses given, and the rates of trauma-related symptomatology were closer to those found in the literature on individuals with mental health and/or substance use issues.

Reimbursement Justification of diagnosis, length of stay, and interventions is required documentation for organizations requesting reimbursement from third-party payers. In the current climate of shrinking benefits and more stringent calls for cost-effective care, health care records must capture all the data necessary to show payers why specific decisions were made, why specific interventions were used or changed, and how well the individual served is progressing toward stated goals. Without this information, reimbursement may be reduced or refused altogether. As mentioned earlier, payers may also require that data be submitted using specific language, forms, and codes. Staff must ensure that the required rules for each payer are followed and that the records of individuals served contain all the necessary data.

Resource Allocation and Management Many behavioral health care organizations use resources and equipment that play a primary role in delivering care, treatment, or services. For example, one facility might offer animal-assisted therapy for individuals with depression, another might use art therapy for children with learning disabilities, and yet another might provide outdoor therapy for adolescents with substance use disorders. The acquisition, use, and maintenance of the equipment, supplies, and/or animals needed for these programs must be monitored. Effectively documenting resource allocation and management affects how the provider organization functions and how well it provides care, treatment, or services to the population(s) it serves.

Keeping Track of Living and Inanimate Resources VisionQuest—a national youth services organization that provides intervention services to at-risk youth and their families—offers residential and other services in Arizona, Texas, North Carolina, District of Columbia, Delaware, Pennsylvania, New Jersey, Florida, and Maryland. One program that has been offered almost since VisionQuest’s inception in the early 1970s is the use of equine-assisted learning. Skilled instructors use horse training to teach important life skills. Another program offered is the Wagon Train experience in which youth travel cross-country via covered wagon and horseback. Because of these programs, VisionQuest has amassed a significant number of horses, which it maintains and tracks at different facilities throughout the country. The well-being and effective use of these horses plays a pivotal role in the effectiveness and safety of the equine excursions, and VisionQuest has devised some systems to help it ensure that operations run smoothly.

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Dennis Call, who is the risk manager for the adventure and equine programs at VisionQuest, worked with the equine staff to develop a tracking system which ensures that the program is safe, the horses are well cared for and appropriately inventoried, the gear is safe and up-to-date, and the staff are able to administer this program effectively. “We have approximately 80 horses and 10 mules throughout the country right now, and we developed the system to ensure that we track and maintain our equine services in a consistent manner,” explains Call. Before launching this tracking system, VisionQuest’s various horse stations around the country did not always operate in the same way and did not always collect the same data on each horse. By establishing a consistent system, Call is now able to track the status of each horse, any accidents or near misses on each excursion, and how well the gear for the horses is being maintained. Because horses can be transferred between facilities, each horse carries a comprehensive record that includes its history, vaccinations, any additional veterinary or medical information, and any changes in status. Because it travels with each horse, the permanent record is not difficult to locate when information is needed. Each facility also maintains its own log and inventory of equipment, which Call can access electronically at any time. The Horse File forms provide VisionQuest with a comprehensive picture of a horse, its location, and any transfers undertaken. “All the contents of the horse’s file are placed in order, as listed on the Equine Inventory Sheet, to bring uniformity,” says Call. “We use the transfer record frequently, as our animals are transferred between geographical locations according to season, activities and events, and census. This form gives us a history if we need to track information on health or behavior issues.” Each horse facility is also responsible for maintaining its own documentation on gear repairs and inventory. This is essential in ensuring that there are no added risks during a wagon trail or other equine-related activity. “It is impossible to ensure that nothing will ever happen during one of these excursions,” notes Call. “Sometimes a horse will have a reaction that you can’t predict or the trail will cause a problem. But there are some things we can do to help mitigate the risks.” He points to taking a careful inventory of gear as an example. “We can lessen the risks significantly by ensuring that our equipment is working properly, so we have put some checks into the process to help us with that.” Safety is also enhanced by teaching youth about the horses, including how to care for them, prepare them for activities, and ride. Staff document when each youth receives instruction in these areas as well as when his or her competency level is deemed acceptable. When staff and youth go on rides off-site, a checklist details all the items that must be packed and processes that must be followed for day activities. These include medications and first-aid kits, proper outerwear, radios, and emergency procedures and phone numbers. Staff at the various horse stations submit information to Call on a regular basis so he can track the horses and equipment to see if any actions need to be taken. For example, a particular horse may need to be rotated out of regular use to rest or a specific piece of equipment may need to be updated.

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Using the tracking system is a part of normal operations. “Our horse staff don’t typically have a lot of background in documentation, but with some training and mentoring, they are all using the system, and we have left the process open so we can make changes or improvements should they be warranted.” Call opted to create a series of forms that are functional yet relatively easy to update. He acknowledges that the organization could have spent more time finessing or formalizing the forms before it began using them, but he finds that the best way to determine the viability of certain documentation is to use it and make modifications as needed. And having a consistent and widespread approach to documentation has helped the organization provide services to its young clients while eliminating as much risk as possible.

Implications of Electronic Health Care Records The technology of electronic health care records continues to advance, and there are many advantages to such recordkeeping systems. Online forms prompt users for necessary information to improve consistency of the data collected in assessments; the elements included in plans of care, treatment, or services; and information provided to individuals served in discharge plans. Software can also help staff aggregate data and create reports more quickly than a manual system. However, there are many factors to consider before converting a paper-based system to a computer-based one. There are financial implications for any organization making the switch, and questions like the following should be answered: • Will we need new equipment, or will our existing equipment need to be upgraded? • How much will the initial software cost, and what will the ongoing fees be? • Do we have adequate in-house expertise to handle questions about and problems with the technology, or will we need to contract with an outside source for support? • How much training will staff need, and how much time will this take away from their normal duties? There are also technical questions an organization must answer: • Will we integrate existing systems in different departments (for example, billing and admissions), or will we start from scratch with a new organizationwide system? • Will records be input into the system beginning at a particular recent date, or will past records be scanned in as well? • How will access to records be monitored and/or restricted so that the privacy of individuals served is protected according to the Health Insurance Portability and Accountability Act (HIPAA) and relevant federal and state privacy and reporting laws? Locating and then assessing software and service vendors can require a great deal of research—and answering additional questions, such as these: • Has the vendor worked with other behavioral health care organizations? • Can the vendor adapt its forms and documents to fit our organization’s needs? • What kind of technical support does the vendor provide? How does it protect against hacking? • How reliable is the vendor’s system? • Does the vendor’s system crash frequently? • If a crash occurs, how long might we be offline?

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All these considerations may make changing over to electronic documentation difficult for some organizations, whether due to cost, time, or lack of other resources. To help organizations overcome some of the obstacles they may face, certain states have ongoing initiatives that have developed standardized electronic forms and manuals for documenting clinical/case records, including assessments; plans of care, treatment, or services; transfer/discharge; and progress notes. These forms meet the various certification, national accreditation, and Medicare/Medicaid compliance requirements, as well as each state agency’s own rules and standards. Organizations within each state can gain access to the tools and forms and have the option of using either the online system or printing out paper forms. Two well-known state initiatives are the New York State Clinical Records Initiative (http://www.mtmservices.org/NYSCRI_2010F/2010-Forms.html) and the Massachusetts Standardized Documentation Project (http://www.abhmass.org/msdp.html). If you are interested in getting help with electronic forms, you may want to check with your state behavioral health care association to see whether it offers assistance in this area.

Paper-Based Versus Electronic Documentation Some organizations have made the move toward electronic records or the use of online forms. Others are using a combination of electronic and paper documentation, while others still rely exclusively on paper-based documents. Whatever your approach may be, you must ensure that your method suits the needs of your staff and population(s) served. Just as the aesthetics of a form are less important than the information it contains, the choice of an electronic or a paper-based system is less important than its usefulness. Software prompts cannot make staff write more individualized needs statements or plans of care, treatment, or service. Regardless of how data are recorded, the accuracy of a record depends on the skill of the staff who gather the information.

Implementation of Electronic Health Care Records Staff at Red Rock Canyon School in St. George, Utah, went through a year of research and planning before changing over the facility’s paper-based records to an electronic system in June 2011. “We started from scratch on the electronic version,” recalls Brian Pace, executive director of this 128-bed residential facility, which provides treatment for troubled boys and girls ages 12 to 17. “We originally had some document forms set up in Word and Excel formats. People printed out the form they wanted, filled it in by hand, and put it in the record.” The team formed to plan the conversion was composed of Pace; the clinical, academic, and residential directors; and the information technology (IT) manager. The first order of business was to find a vendor that could provide the software, storage, and support Red Rock needed. The team looked at a variety of basic factors for each vendor, including the following: • Reputation in the field • Timeliness and friendliness of responses from customer service • Willingness to adapt the system for behavioral health care • What support and training were included in the monthly fees • Reliability and security of the system

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A Practical Guide to Documentation in Behavioral Health Care, Fourth Edition

Pace expressed his satisfaction regarding the vendor Red Rock eventually went with, describing it as being “put together by IT people who came together with program people. They took the time to do some research on behavioral health programs and what they need—it’s not the hospital level of care. Then they put that together with our facility’s needs.” Red Rock already had enough computers to accommodate staff needs. Although it wasn’t necessary for the new system, the conversion team decided to upgrade the organization’s existing equipment to reflect more recent technology, such as updated monitors. One upgrade that was essential to the new system was getting a faster Internet connection so that all buildings at the facility were able to access the system at the same speed. Red Rock staff began working with representatives from the selected vendor to adapt the facility’s existing forms to the electronic system. Each group (clinical, academic, and residential) met to go through the templates provided by the software company and how it worked. Then the templates were adapted to meet Red Rock’s specific requirements as much as possible. According to Pace, “We wanted to make sure that all our questions were on the assessment. We wanted all our objectives and goals on our treatment plan. We wanted our group notes to look a certain way because we have certain ways we track and measure those.” This process took a total of about 12 weeks for the three groups. Although some of the forms looked much the same after being converted to the electronic system, others covered the same information but were not formatted the same way as the original. (See Figure 1-3 on pages 19 and 20 for one of Red Rock Canyon’s converted forms.) Another important area that needed to be addressed was confidentiality and security. “With the [paper] system we had, there were many users,” explains Pace. “We had to determine who those users were and go through a selection process of who we really thought should have access to the electronic files. We’re still working on it.” Staff were given intensive training in HIPAA requirements, including how information was to be communicated in notes and e-mails. The software system allows unlimited access to some people, specifically to Pace and the department heads, and limited access to others on staff. For example, billing personnel can access the data from a resident’s record that is needed to apply for reimbursement, but they cannot read specifics about the resident’s treatment plan or response to treatment. Training staff in how to use the new documentation system took about six months. The clinical team, academic team, and residential team each went through six training modules; each module consisted of a weekly 45-minute session. Pace, the IT manager, and the department directors were given an extra hour of training so they could help others with problems and learn how to access all parts of the system. The vendor’s monthly fee includes unlimited webinars, phone calls, and training, and Red Rock has access to technical assistance at all times. “It took some of the clinicians a while to adapt to the computer from written notes, but they conformed and did well. Now they love it,” says Pace. “You go in and take a look at each part of the record right after it’s done; you don’t have to wait a couple of days until it’s entered. You click on a specific part of the file and see what’s been done— the latest phone calls, the latest treatment goals.”

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Section 1: Basic Documentation Components

Figure 1-3. Electronic Version of Red Rock Canyon’s Master Treatment Plan

(continued)

Red Rock’s master treatment plan, as formatted for the electronic system, illustrates how the form is completed by clinicians online.

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A Practical Guide to Documentation in Behavioral Health Care, Fourth Edition

Figure 1-3. Electronic Version of Red Rock Canyon’s Master Treatment Plan, continued

Source: Red Rock Canyon School, St. George, Utah. Used with permission.

Check the CD for an electronic copy of this form.

What are some of the lessons Pace and Red Rock learned in making the transition from paper to electronic files? According to Pace, “You need to look at your program and decide whether you really want to make the commitment to go electronic because if you go half-and-half, it can be frustrating. You end up losing information, or the process gets difficult because some people are working electronically and some aren’t. It’s almost a paradigm shift. You have to tell people, ‘We’re doing it this way now.’” Another challenge the organization faced was deciding what forms actually needed to be included in the system. Red Rock staff looked at some of the paper documents that were being used to determine whether they were really needed or whether they could be combined. They also created guidelines for which old records were to be scanned onto DVDs for storage and which recent records were to be input into the electronic system for storage. Pace’s final advice: “Research all the vendors out there. Keep in mind that no model can be customized 100% to your needs, but you should be able to find one that you can live with. Look for [a software provider that] is honest and upfront—‘No, we can’t do that. Yes, we can do that. If we do this, we’ll have to charge you a little bit more.’ I wanted to know what happens if their three servers

20

Section 1: Basic Documentation Components

get full; will they crash? Also, what if they get hacked? There’s a lot of proprietary information in your files. So find out about their liability. And make sure the company is willing to work with you and that they’re willing to adjust their program to evolve with the times.”

Ensuring Quality Quality documentation is an essential tool in behavioral health care organizations. A system of any kind requires continuous feedback loops to evaluate outcomes and processes so that any unacceptable performance can be detected promptly and restored to acceptable standards of practice. The main components of the care, treatment, or services process—data collection, data assessment, action planning, and action implementation—form this type of loop. Each step in the care, treatment, or services process has equal merit, and each step builds on its predecessor. The quality of the intake/admission assessment affects the quality of the plan of care, treatment, or services. If an intake assessment fails to detect or omits important information, each subsequent step in the care, treatment, or services process is affected. The process of providing care, treatment, or services needs to be seamless, dynamic, and cumulative. Documentation tells the story of the care, treatment, or services process from an individual’s first contact to the point of transfer or discharge. Complete and accurate data allow for appropriate diagnoses and plans of care, treatment, or services. Well-written objectives and goals justify the use of specific interventions to payers and regulators. Timely and complete documentation of an individual’s responses to care, treatment, or services facilitates communication among staff who work with that individual and may indicate a need to review the plan of care, treatment, or services. Support functions, such as performance improvement, billing and reimbursement, and resource allocation, also require good documentation. These functions are essential to the care, treatment, or services process and keep the organization operating and viable. Although electronic health care records are becoming more common, establishing them may be costprohibitive or otherwise impractical for various organizations and programs. Whether an organization uses a paper-based or an electronic documentation system is less important than how that system is used to facilitate care, treatment, or services.

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