Hill Country MHDD Centers Progress Note Technical Assistance Workshop for DSHS Mental Health Contractors Adapted from Substance Abuse Division Quality Management Unit DSHS Mental Health Hill Country MHDD Centers

Purposes of Progress Notes: 1. Tell the story of the recovery journey Purposes of Progress Notes: 1. Tell the story of the recovery journey. 2. Treatment Record 3. Means of Reimbursement 4. Certification 5. Communication tool for staff

The Language of Progress: 1. Write as if the person served is looking over your shoulder, using: respectful, culturally sensitive, and recovery-oriented language 2. Documentation is to be neat & legible 3. Only written or printed in black ink. 4. Sign your name in full, with your working title. 5. Document accurately at the time of the contact. (Collaborative Documentation) 6. Do not leave spaces where others can write. Draw one diagonal line through any blank space left with initials, and date. 7. To correct an error, draw a single line through the entry, write error, and initial and date the error. Never use whiteout! 8. All documentation must be exact and an accurate description of the actual events as they occurred. * Forging, altering, or deliberately falsifying documents, authorizations or records is illegal and will, therefore result in termination of employment and possible legal prosecution.

The Language of Progress cont. A progress note is the shortest way to communicate the essential information. Remember your reader and who may have access to the medical record. As such, do not use names other than that of the individual in the progress note. Do not write about subjects beyond your qualifications or expertise. If you cite an authority, make sure they are qualified. Make sure you identify where you got information. Only include information that is necessary and pertinent to treatment. Use a clear progression of statements, and be simple and precise in your descriptions. Use quotes to establish understanding. Be specific, nonjudgmental, and factual!!

PROGRESS NOTE REQUIREMENTS All Mental Health Contractors

Progress Note Requirements Except for crisis services, day programs for acute needs, and case management services, a provider must document during the provision of the service all mental health community services, each service encounter and include at least the following: continued ……………. Texas Administrative Code §412.326(a-b)

Progress Note Requirements the name of the individual to whom the service was provided, including the LAR or primary caregiver, if applicable the type of service provided the date the service was provided the begin and end time of the service the location where the service was provided the modality of the service provision (e.g., individual, group) the method of service provision (e.g., face-to-face, phone, telemedicine) the psychiatric rehabilitation methods used, if applicable (e.g., instructions, modeling, role play, feedback, repetition) continued…………… Texas Administrative Code §412.326(a)(1-6)

Progress Note Requirements summary of the activities that should answer the following questions: 1. What was the treatment plan objective(s) that was the focus of the service? 2. Psychiatric Rehabilitation techniques used to produce change. 3. Client statement about how what they accomplished in session will or will not help them reach their goal. 4. Any pertinent event or behavior relating to the individual’s care which occurs during the provision of the service. 5. Statement of progress, or lack of progress, stated in terms that are both observable and measurable in regards to what was accomplished in session today as well as rationale that supports your assessment, and how progress will help achieve recovery plan goals & objectives. continued……………. Texas Administrative Code §412.326(a)(7-11)

Progress Note Requirements the signature of the staff member providing the service and a notation of credentials (LPHA, QMHP-CS, pharmacist, CSSP, LVN, peer provider or otherwise credentialed, as required for that service) any pertinent event or behavior relating to the individual's care which occurs during the provision of the service Texas Administrative Code §412.326(a)(12-14)

WHY COLLABORATIVE DOCUMENTATION?

Benefits of Collaborative Documentation: Allows more face to face time in the month with individuals on your caseload. Improves accuracy & compliance in data collecting. Improve individual/family engagement and involvement. Helps reinforce/review material taught in session. Relieves stress of having days/weeks of unfinished notes to do at the end of the month. Helps ensure continued employment. Claims are reimbursed, we are able to stay open, and individuals are able to continue receiving services.

Final Comments

Sources Gilman, Peter B, PhD. A New Era of Documentation in Psychiatry: Advice on Psychotherapy Progress Notes. Behavioral Healthcare Tomorrow, February 2004. Bowden, Kirk MA, CPC. Clinical Documentation and Case Report Writing. Arizona: Rio Salado College, 1999. Janis Tondora, Psy.D., Assistant Professor, Department of Psychiatry,Program for Recovery & Community Health Yale University School of Medicine

Contact Information Debra McIntire, Quality Management Specialist debra.mcintire@dshs.state.tx.us