Documentation Documentation Documentation tells a story Quality documentation

Documentation

Documentation… Documentation tells a story Quality documentation tells a story that everyone can understand What does your documentation say about you?

Financial implications Documentation is a receipt, warranty and guarantee for payments received. You cannot afford to have bad documentation An auditor can take money back when services are not appropriately documented.

Ethical Implications Documentation outlines your activities with consumers. Our profession expects documentation. Your documentation is not written to win a lawsuit, rather to prevent a lawsuit. Document what you have done to ensure the client’s safety. Also document why you didn’t use certain lesser restrictive interventions. It is part of our code of conduct.

Professional Implications Other professionals read your documentation. Your documentation can be subpoenaed for legal purposes. Caregiver or licensing can reprimand you. Caregiver or licensing can revoke your ability to work in this field. It is a professional expectation.

Documentation Tips Document to show your thought process and why you did what you did. Make your documentation obvious. What you write will be show what you consider as most important. Use quotes if possible, from everyone. Write why you didn’t use certain interventions.

Risk Management Tool Documentation outlines your activities with the consumer. Documentation protects the consumer. Documentation improves the continuity of care for the consumer. Documentation protects the professional as it communicates your clinical judgment. Quote direct statements when appropriate.

Liability v With good documentation- liability decreases v Without good documentation- liability increases v Practice standards- quality documentation ensures healthy and quality standards

Remember… v Documentation is one of the most important aspects of your work v If it is not documented, it’s very difficult to show what happened

Overall Guidelines v The record must be legible and complete. v Do not leave blank spaces v Use professional language-be aware of the fact that outside parties read our charts (licensing, courts, etc. ).

Overall Guidelines (Continued) v Slang terminology should be used only when quoting individuals. v Report the facts. Use quotes when appropriate and useful. v Avoid judgmental/derogatory descriptions v Obtain information regarding support persons- phone numbers, addresses, signature etc. This assists in representing good faith effort.

Importance of Spelling Historical Information Previous Contacts Crisis Plan Legal Obligation

Spelling Activity http: //www. youtube. com/watch? v=9 Via. Bg. G 7 s. Mw Spelling Test-Trainer see your handout provide names before moving to next slide

Sierra Brazee Monika Hyde Kristoffer Laffin Deputy Boushon Iris Coakley Ciera Johnson

Emergency Services Assessment NWC Specific Documentation

Demographics Crisis Plan/Alert Insurance Student Veteran Race/Ethnicity County/Billing and Reporting Codes-see handout Parent/Guardian(not just children) Supports

Logistics THIS SLIDE IN CONSTRUCTION

Mobile Crisis Worker Name Credentials Travel Mileage Travel Time(minutes) Assessment Time(minutes) Documentation Time(minutes) Total Time(minutes and convert to units) Units-Handout

Telephone Crisis Worker Name Credentials Contact Begin Time(military time) Contact End Time (military time) Total Contact Time (minutes) Documentation Time(minutes) Total Time(minutes then convert to units) Units-Handout

Assessment Client’s perception of the situation and desired outcome (include an inquiry about changes in daily activities sleep, appetite, environmental safety): Are you currently under the influence of alcohol or other substances? Please describe your alcohol/substance use: Are you currently receiving any services related to your mental health (i. e. therapy, psychiatrist, county programming) If Yes- what services/program, where and contact information if available: Self or collateral reported diagnosis: Have you ever been admitted to a behavioral health hospital/unit? Was this voluntary /involuntary, when and where: Are you currently taking any medications (prescription/over the counter)? If yes what are they and do you take them as prescribed? Do you have any current medical issues or concerns? Have you ever intentionally harmed yourself (i. e. cutting, burning, etc. )? Legal status and history (i. e. probation, parole, civil commitment, guardianship: Does the client have access to firearms, potential hazards or items that are part of an identified plan of self-harm and/or suicide? If putting information obtained from another party clearly indicate who is providing this information

AODA Factors What substances has client used today or in their history? And description of use. Is client currently or soon to be going through detox? What is a PBT/BAC Withdrawal Symptoms Where these observations Notifications from medical staff Supports reports

Self Harm/Deliberate Self Harm Superficial Scratching Burning Lacerations Banging Descriptions: What do those mean Level of medical intervention necessary/received Use quotes if needed

Collaboration-Columbia COLUMBIA-SUICIDE SEVERITY RATING SCALE Ask Questions 1 &2 address context of responses in the narrative 1. Have you wished you were dead or wished you could go to sleep and not wake up? 2. Have you actually had any thoughts of killing yourself? IF YES TO 2, ASK QUESTIONS 3, 4, 5 AND 6. IF NO TO 2, GO DIRECTLY TO QUESTION 6 Address context of responses in the narrative 3. Have you been thinking about how you might kill yourself? 4. Have you had these thoughts and had some intention of acting on them? 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? How long ago did you do any of these? Are you having thoughts or feelings of wanting to harm or kill someone else If Yes: Have you ever done anything or prepared to do anything to harm/kill someone:

Summary of Assessment Initial Contact Concerns Who made contact with the Emergency Mental Health Services System What were the circumstances resulting in contact with Emergency Service and the point of contacts concerns/requests Officer Smith of the Gatwick Police Department contacted Northwest Connections concerning John Doe. Officer Smith reported John’s sister Suzie Q contacted law enforcement tonight after John and his girlfriend got into a verbal argument and John texted his sister stating “I hate my life and don’t want to be here any longer”

Summary of Assessment Summary of Contact(s) Outline who you interviewed Their perception of the situation The outcome they initially wanted see occur (if known) Any additional information you obtained that assisted in your decision making If utilizing clinical consultation include that consultation outline in this section Quotes related Remain objective and non-judgmental

Documenting-Mental Status Observations Possible descriptors: Appearance posture, clothes, grooming Behavior Mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests, compulsions.

Documenting Speech Possible descriptors: Talkative, spontaneous, expansive Fast, slow, normal, pressured. Loud, soft, monotone, weak, strong. Slurred, clear, with appropriately placed inflections, hesitant, with good articulation,

Affect-Observed Appropriateness to situation, consistency with mood, congruency with thought content. Fluctuations: Labile, even. Range: Broad, restricted. Intensity: Blunted, flat, normal intensity. Quality: Sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable.

Thought Processes-WORKING ON

Documenting Strengths: insight into current situation/ status healthy hobbies/ interests/ coping skills cooperative when talking with you, are they asking for help, do they seem honest throughout the interview? did they give up things they could or have harmed themselves with? how have they managed to cope in the past?

Summary of Assessment Response Plan-Risk Factors/Warning Signs Identified: WORKING ON THIS SECTION

Summary of Assessment Response Associated with the outcome State what the outcome is Why other tiers were ruled out Any other important information Who agreed with this plan How long is this plan in effect Who will participate

Example of Tiers Outline The client was not appropriate to remain home alone, due to her continued suicidal thoughts, plan and attempt this day. The client was not appropriate for a telephone stabilization plan in her home due to her home being the location of her medications(unwilling to have someone secure) and no available supports with her current suicidal ideation and plan The client was not appropriate for a community response plan with supports as supports identified refused to provide supervision and client refused to go with supports or have supports be with her

Tiers Continued A crisis bed was explored and discussed however, the client refused to go voluntarily to the crisis bed. A voluntary admission to a inpatient hospital was discussed and the client stated she did not need a hospital and adamantly stated “I don’t need or want any help” An emergency detention was approved on this date under criteria for Mental Illness as evident by self reported diagnosis of bi-polar disorder as well as “hopelessness”. Dangerousness to Self as evidence by consumption of a full bottle of alprazolam and being found unresponsive. Continued risk of dangerousness as client indicated frustration that her attempt did not work “clearly I need to take more”.

Sample Response Plan : John is remaining in the community with the support of his sister tonight. Although John confirmed that he had sent that text to his sister he denied it was a presentation of suicidal ideation or intent. He stated his intent was to express his desire to no longer be living and fighting at his girlfriends. He stated he understands his sisters concerns given history of suicidal threats about eight years prior. John was also able to identify the plan for the night, and Suzie Q(sister) agreed John could remain with her and she would be home for the next 24 hrs. to provide support. She said she felt comfortable contacting emergency services at a later time if further concerns presented themselves. John also agreed to contact emergency services if he needed assistance. John identified intent to contact his previous therapist about possible appointment on Monday. Officer Smith and this worker were in agreement that James would be safe to remain in the community tonight.

Additional Items Addressed in Response plan Recommendation to secure firearms communicated to: Recommendation to secure other potential hazards such as medications communicated to: Location of Bed (hospital, crisis bed, CSCN): Admission Confirmed Admission Confirmation Plan Created Transportation provided by: Client is going to Jail: Precautions recommended and communicated to: Recommendation that no precautions were needed No recommendations were communicated Medical Treatment Primary – Location: Telephone Stabilization Plan Created

Signatures • Signatures need full name and credentials. • Typing your name is not a signature

Credentials Credential or qualifications are defined as follows: Anyone with a mental health related Master’s degree or above should sign with their degree abbreviation (MA, MSW, Ph. D. , etc. ). All licensed professionals should sign with the appropriative abbreviation for their license. Anyone with a Bachelors Degree in a human service related field should sign with their degree (BA, BS, etc. ). If someone has a set of circumstances that does not neatly fit on this guide, please check with your supervisor who will direct you what to put

Documentation Time Expectations It is the expectation of Northwest Connections that billable documentation time shall not exceed 45 minutes in time. This expectation was developed by reviewing content and documentation that is currently being provided. If you are struggling to meet this expectation reach out to a supervisor This may be difficult when first starting out.

Documentation Submission Documentation is due to the county by 8 am on the next business day. Each county documentation submission option(s) may be a bit different. We understand that there are situations that can lead to a need for documentation to be late on occasion. Due to the nature of county employees follow up and linkage expectations you must contact your county contact person if you are going to be late in documentation submission. Note-documentation is your typed assessment-your notes from your assessment are not to be sent.

What is due to the County? Typed crisis assessment- including your signature Mobile Specific: Crisis Assessment Signature Response Plan Release of Information Rights and Grievances signature page Any County Specific Items Your notes do not need to be turned into the county.

Confidentiality in the Community Create a password protected User Account for personal computers being used – see computer items handout Any documents with client information must be kept in a locked/secured area no one has access to Vehicle – lock in trunk Desk or other location at home – locked in desk drawer, file cabinet, etc. Remember you can save blank forms on your computer to use; you just cannot have forms with consumer information on your computer.

Security on a personal computer-Mobile Click on start Go to the Control Panel Select User Accounts Select Manage Another Account Click Add a New User Enter a name for User Select Administrator account type; if a password is currently used you will have to enter it Click Create Account Upon creating account; again go back to User Accounts Click on the account you just created Click Add/Change your Password Enter a password – do not share this desktop with others See mobile computer handout

Mobile-Saving the Assessment Complete document on your desktop and “save as” Smith, John. mobile. 01. 10. 13

Mobile-Supporting Documents If scanning documents separately — save on desktop as: If a Mobile Crisis Assessment – Smith, John. mobile. 01. 10. 13 If a Mobile Crisis Assessment Signature – Smith, John. signature. 01. 10. 13 If a Mobile Crisis Response Plan – Smith, John. response. 01. 10. 13 If a Mobile Assessment Release of Information – Smith, John. ROI. 01. 10. 13 If a Mobile Assessment Rights and Grievances page – Smith, John. rights. 01. 10. 13 If a County Specific Items – Smith, John. other. 01. 10. 13 If scanning all items together Smith, John. mobileitems. 01. 10. 13

Destroying documentation(mobile) It is important to destroy any documents you create or obtain related to a client after contact. Please verify that the documents have been received prior to destroying any documentation. Hard copies: Proper disposal of client paperwork is shredding or burning.

Destroying documentation Deleting items from your desk top: It is imperative that if you work from home on a personal computer that following inputting your documentation you delete that document off of your hard drive. To do this: Select the document hold down shift and delete Select yes when “Are you sure you want to delete. . . ” comes up Remember you can save blank forms on your computer to use, you just cannot have forms with client information on your computer

Using our Portal

County Specific Packets

Onsite-Carbon Response Plan Complete, review/ read response plan with all parties and have everyone sign it Distribute copies to all involved parties- a copy should go home with the client so they remember what they agreed to Consider follow up and include in the plan Keep a copy for your records and to demonstrate good faith effort. Document with whom and how you communicated or consulted. Does your documentation demonstrate your best faith effort Samples of the carbon response plan are located in your training binder

References and Resources http: //www. youtube. com/watch? v=9 Via. Bg. G 7 s. Mw