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This course provides training and CEUs for addicitons counselors and LPCs working in Addictions, Mental Health and Co-Occurring Disorders will help counselors, social workers, marriage and family ...

This course provides training and CEUs for addicitons counselors and LPCs working in Addictions, Mental Health and Co-Occurring Disorders will help counselors, social workers, marriage and family therapists, alcohol and drug counselors and addictions professionals get continuing education and certification training to aid them in providing services guided by best practices. AllCEUs is approved by the california Association of Alcohol and Drug Abuse Counselors (CAADAC), NAADAC, the Association for Addictions Professionals, the Alcohol and Drug Abuse Counseling Board of Georgia (ADACB-GA), the National Board for Certified Counselors (NBCC) and most states.

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4 hours documentation Presentation Transcript

  • 1. Documentation 4 Hours
    Instructor:
    Dr. Dawn-Elise Snipes Ph.D., LMHC, CRC, NCC
  • 2. Explanation of
    Informed Consent/Payment Rules
    HIPAA Notification/Confidentiality
    Releases of Information
    Client Rights and Responsibilities
    Grievance Procedures
    Clearly written admission and discharge criteria
    Identification of person responsible for service coordination
    Program rules
    Description of purpose and process of assessment
    Orientation
  • 3. Name
    Age
    Address (911 and mailing)
    Emergency Contacts
    Insurance
    Demographic Information
  • 4. Presenting Issue
    Impact on psychosocial functioning
    Eligibility for services
    Appropriateness of services
    Screening
  • 5. Presenting Problem
    Mitigating/Exacerbating
    Duration/Intensity/Frequency
    Exceptions
    Mental Status
    Urgent Needs
    Psychosocial/Developmental History
    Personal Strengths, Needs, Abilities, Preferences
    Employment/School
    Legal Involvement
    Substance Abuse
    Collateral Evidence
    Assessment
  • 6. Prior Treatment and Effectiveness
    Abuse history
    Relationships and Supports
    Special Considerations
    Assistive Technology
    Risk Taking Behaviors
    Cognitive Functioning
    Disabilities
    Spirituality
    Assessment cont…
  • 7. Presents a comprehensive picture of the development of the problem
    Supports diagnosis
    Identifies person’s goals
    Identifies any referrals made
    Identifies interventions based on the persons SNAP
    Integrated Summary
  • 8. Drugs taken
    Side effects
    Interactions
    Abuse
    Medical Conditions
    Differential Diagnosis
    Co-Occurring Disorders
    Drug Profile/Medical History
  • 9. Words of the Person Served
    Solution Focused
    Strengths Based
    Observable, Measurable Goals
    GoalsObjectives (subgoals) Interventions
    Progressive KSAs
    Based on information from integrated summary
    Realistic Goals and Timeframes
    Treatment Plan
  • 10. Focuses on integration into
    Community
    Family
    Natural Support Systems
    Other Needed Services
    Interventions are consistent with
    SNAP
    Age
    Development
    Culture
    Identifies and links with services to meet needs beyond the scope of the program
  • 11. Completed after every contact
    Mental Status Exam
    Progress on assignments from last visit
    Review referrals
    Review progress on treatment plan
    Document any changes in treatment plan
    Set goals for next session
    Make new referrals as needed
    Document any case consultation
    Progress Notes
  • 12. Every 30 days
    Ensures adequate progress on treatment plan
    Identifies needed changes
    Provides positive reinforcement for progress
    Reassessment
  • 13. Name of person served
    Integrated summary including SNAP
    Description of reason for referral or transfer
    Contact information for referrer
    Referrals and Transfers
  • 14. Is a summary of treatment and progress
    Mental Status Exam
    Discusses progress on each treatment plan problem
    Identifies services provided
    Identifies current medications and dosages
    Discusses progress toward overall goal
    Discusses plans for future activities
    Provides necessary referrals
    Given to person served
    Discharge
  • 15. Excellent Guide to Clinical Documentation
    Includes blank forms as well as completed examples
    HIPAA compliant
    The Clinical Documentation Sourcebook
    Resources
  • 16. Provides information for future providers
    Protects against legal actions
    Acts as a road-map to help clients progress
    Helps clinicians stay on track
    Summary