GOOD CLINICAL DOCUMENTATION WITHIN

CCSTamara Layne MS, OTR/L

Integrated Services Coordinator

Milwaukee County’s Community Access to Recovery Services (CARS) Branch

WHY IS CLINICAL DOCUMENTATION IMPORTANT?

WHY IS CLINICAL DOCUMENTATION IMPORTANT? (CONTD.)

Documentation in the medical record:

1) Supports the service provider in demonstrating the need for service

2) Tracks the course of treatment and progress as it relates to the IRP

3) Serves as a valid “receipt” of service for payer sources (insurance

companies, T-19, CCS, etc.)

4) Protects and/or assists the provider to testify in situations where

legal action is being taken

5) Is an essential communication tool for Recovery Team members

KEY ASPECTS TO REMEMBER ABOUT DOCUMENTATION

If you didn’t write it down, no one knows it happened

Your records might be viewed by: Judges Attorneys Consumer Guardian State

MINIMIZE THE RISK OF LIABILITY

WARNING: INCLUDING ANY OF THE FOLLOWING ITEMS IN YOUR

DOCUMENTATION MAY RESULT IN A LIABILITY ISSUE

1) Recording a “to do” item in the case file and not following through

2) Negative, biased, or prejudicial language

RECOMMENDATIONS FOR WRITING GOOD CLINICAL

PROGRESS NOTESMake sure that your progress notes are:

Factual Objective; unbiased Specific Clear and to the point Omit details of clients lives that do not have an

impact on care plan Avoid using medical diagnoses that have not

been verified and/or diagnosing if you are not qualified

According to DHS 36.18 (3)(e)….The consumer’s service record MUST include:

Service facilitation and progress notes

Records of referrals to outside resources

Descriptions of significant events, that are related to the

consumer’s care plan and contribute to an overall

understanding of the consumer’s ongoing level and

quality of functioning

Evidence in the consumer’s progress, including response

to services, changes in condition and changes in services

provided

According to DHS 36.18 (3)(e)….(Continued)

Observation of changes in activity level or in

physical, cognitive or emotional status and

details any referrals

Case conference and consultation notes

Service provider notes in accordance with

standard professional documentation practices

DOCUMENTATION EXPECTATIONSMilwaukee County will be regularly reviewing CCS documentation to ensure compliance with outlined standards

When documentation is being reviewed, we expect to see the following:• Date and time service occurred• Duration of the service (how many units)• Nature of the contact i.e. face to face, phone

call, etc.• What services (specifically) were provided• Documented services justify the recorded

duration of the contact

DOCUMENTATION EXPECTATIONS (Continued)• Services are rehabilitative in nature

• The service(s) being provided link back to a specified goal(s) on the IRP

• Progress and changes in condition/service are clear and evident

• If there is an observation related to a mental, physical, or emotional

change, it has been addressed (or there is a plan to have it addressed)

• If an individual is mentioned in the case note, their relationship to the

consumer is also mentioned

• There is a plan at the end of each note indicating what will occur

between contacts followed by the “Next Contact” “Date”

CASE NOTES SHOULD DEMONSTRATE THE CCS

PROCESS1) The steps in the CCS process should be clearly documented from intake to discharge

2) Highlight the completion of important CCS related paperwork

3) The more specific you are, the better reference point your documentation serves

NON-BILLABLE SERVICES

Filing information in the client’s medical record Transportation without service provision Waiting in the lobby while the consumer is in

an appt. Outreach efforts prior to signing of Application

and Admission Agreement Recreational activities – cannot bill for

“Went to the museum and had fun.”

1) What is the relation of this activity to the IRP?

2) How is it rehabilitative in nature?

NON-BILLABLE ACTIVITIES (Continued)

Unless an Abbreviated Assessment and IRP have been created to address urgent and immediate needs, no service delivery outside of screening/assessment, service planning/facilitation should be provided before the development of the IRP

Going to the client home and the client is not there Calling the client and leaving a message (if the case

note is written this way)

CASE NOTE SAMPLE:1

7/5/15 at 1:30 PM (10 units) This Care Coordinator Jen Jordan and Supervisor/Care Coordinator Jessica Morton met

with Cl at the clinic to review the CCS program with Cl. CC provided Cl with information

regarding the CCS program/service array and Cl expressed interest. Cl was made aware that

he would need to transfer to a CCS therapist which he was agreeable to. During this

initial visit we completed the CCS application and signed the service agreement. We

reviewed and signed agency specific paperwork such as authorizations, No Contact Plan,

Identity Verification Form, HIPPA, Rights and Grievance, and weather related safety

information. CC collected information for the MH/AODA functional screen to determine

eligibility. CC notes that cl was pleasant and cooperative throughout this process. JJ Electronic signature

WHAT MAKES THIS AN EXCELLENT CASE NOTE?• Date and time service occurred

• Duration of the service (how many units)

• What services (specifically) were provided

• Documented services justify the recorded duration of the contact

• If an individual is mentioned in the case note, their relationship to the

consumer is also mentioned

• If there is an observation related to a mental, physical, or emotional

change, it has been addressed (or there is a plan to have it addressed

• IMPORTANT: This is a CCS Intake note. The level of detail is perfect. Not

all expected case note components will always apply

• TO OBTAIN COMPLIIANCE ON THIS NOTE : Include nature of the

contact i.e. face to face, phone call, etc. and a plan at the end of the

note as well as the “Next Contact” “Date”

CASE NOTE SAMPLE: 2Goal on the IRP: MJ will meet with CPS who will support MJs goals and encourage socialization.

76/15 9:00AM (30 units)Certified Peer Specialist accompanied MJ to art therapy at St. Luke's. Consumer

disappointed to find he had the wrong day. Consumer takes a lot of pride in his art work and has some of it hung up in the waiting room. We then went to Omega for breakfast. We

went to Walmart for a few things then went back to his home. We talked about the usual things one thing was his frustration with his family not accepting him. He had a smoker move in below him which made him very angry because they had told him they wouldn't do

that. I allowed him to vent and also pointed out that one can't change people unless people want to change. Also, that he might have to accept the relationship as it is. I spent over an hour trying to negotiate a good price from AT&T for a cable, computer and wireless. CPS was unable to get a better price. CPS sent AT&T to payee because they quoted her a wrong price and CPS could not authorize the higher price

WHAT ARE THE ISSUES WITH THIS CASE NOTE

• While their appears to be socialization going on during the contact,

there is not direct reference to what is being worked on

• There is also A LOT of took client here, took client there. CCS does

not pay for transportation. You need to clearly be providing a CCS

service when you are billing transportation time

CPS attempted to negotiate an AT&T bill for the consumer 1)This is

NOT rehabilitative in nature as you are doing the service for the

consumer nor is this the CPS’s role as this is not written on the IRP

CASE NOTE SAMPLE 2: OTHER AREAS NEEDING IMPROVEMENT FOR

COMPLIANCE• What services (specifically) were provided

• Documented services justify the recorded duration of the contact

• Services are rehabilitative in nature

• The service(s) being provided link back to a specified goal(s) on the IRP

• There is a plan at the end of each note indicating what will occur between contacts followed by the “Next Contact” “Date”

CASE NOTE SAMPLE: 3

7/7/15 11:00 AM (4 units)HV w/ Ms. Jones. She looked

awful-clothes dirty, hair dirty, hair messed up. She

stunk. The apartment smelled liked pee. As usual, she

complained of not feeling good. Told her to go see her

doctor. Will call SHC coordinator to find out if she

knows anything about why Mrs. Roberts stinks.

FIRST MAJOR ISSUE WITH THIS NOTE: Unprofessional,

biased and disrespectful.

WHAT ARE THE ADDITIONAL ISSUES WITH THIS CASE NOTE?

• What services (specifically) were provided

• Documented services justify the recorded duration of the contact

• Services are rehabilitative in nature

• The service(s) being provided link back to a specified goal(s) on

the IRP

• Progress and changes in condition/service are clear and evident

• There is a plan at the end of each note indicating what will occur

between contacts followed by the “Next contact” “date”

CASE NOTE SAMPLE: 4IRP Goal: Jack wants someone to assist him in taking his medications and understanding what his medications are for as well as identifying the side

effects of his medications7/14/15 8:30 AM (5 units) I coordinated with Recovery, Inc. to set up the delivery of Jack’s medications. Jackwas in a good mood and I watched Jack fill his medication strips for the next week. Jack had mentioned that he would like to keep his medication fill date on Wednesdays in the AM. I did not see a problem with this and told him this would work well but I had to make sure it was alright with Recovery, Inc. Jack took his AM medication in front of me.Jack reported that he had missed a dose of medication over the weekend due to forgetting and that he felt his Symptoms gradually returning. I encouraged Jack to contact his care coordinator if the symptoms got any worse and he felt he needed any kind of intervention. Jack stated that he felt that now that he was back on track with his medication and that he would be fine.

Plan: Jack and I will meet again on June 24, 2015 to give him medication for the next week.

WHAT MAKES THIS AGOOD CLINICAL CASE NOTE?

• Date and time service occurred

• Duration of the service (how many units)

• Nature of the contact i.e. face to face, phone call, etc.

• What services (specifically) were provided

• Documented services justify the recorded duration of the contact

• Progress and changes in condition/service are clear and evident

• If there is an observation related to a mental, physical, or emotional change, it has been

addressed (or there is a plan to have it addressed)

• If an individual is mentioned in the case note, their relationship to the consumer is also

mentioned

• There is a plan at the end of each note indicating what will occur between contacts

followed by the “Next contact” “date”• From a compliance standpoint, the majority of good case note elements are present. As far as service delivery, this note would’ve been better if

medication education was occurring and documented, as this is listed on the IRP as being a desire of Jack’s to learn about his medications• The other question is related to Jack wanting a contact changed to a certain day, and the provider needing to check-in with Recovery, Inc. to make sure this is “alright.” CCS is a consumer-driven program. If a consumer wants to change a day or the frequency of a contact, service providers do not need to

ask permission from the care coordination team to honor this, they simply need to inform them that this is what the consumer wants to do so they are aware and can adjust accordingly

CASE NOTING IN PROVIDER CONNECT

All CCS providers will enter case notes into

Provider Connect

Billing is attached to your case note in PC so

billing won’t need to be entered separately

PC will allow the opportunity for CCS providers

on a designated Recovery Team to review each

other’s case notes

CASE NOTING IN PROVIDER CONNECT

Special consideration for Psychotherapy notes-

Psychotherapy notes need to strictly meet the standards

outlined in 36.18 (3)(e). Under this service, the level of detail

typically kept in a therapist’s record does not need to be

entered into Provider Connect. Due to HIPPA and privacy

standards, a Release of Information needs to be obtained

from the consumer in order for a provider on the CCS

Recovery Team to view psychotherapy notes

TIPS AND TECHNIQUES TO CONSIDER

Carry a note pad with you at all times

Keep a note pad near your phone

Save a half hour each day to do case noting

Set aside paperwork days and put it on your calendar

Talk to a co-worker who does case noting well to learn from him/her

Secure protected time

Is it possible to turn your phone off for a half hour

Say “no” to other tasks

KEY POINTS: IMPORTANCE OF GOOD CLINICAL

DOCUMENTATIONGood Clinical Documentation: Provides a Picture of the Recovery Process

Supports the need for services

Provides Protection

Keeps you focused on what you are working on and why

THANK YOU