We are only writing notes for those services that are Medicaid eligible.
Module 4 5a
Medicaid Reboot Module 4 and 5aEllie Feldmann, LCPCAugust 2012Service Definition and Progress Note Training
• Participants will:– Understand required elements of servicedocumentation– Understand Part 132 service definitions– Integrate understanding of requirements intowriting– Effectively review service documentation forcomplianceLearning Objectives
All documentation should focus on or relate to the client’s identified MENTAL HEALTH NEEDSClinical needs areidentified through theMHAThe needs identifiedlead to a diagnosis forthe clientClinical needs anddiagnosis are used tocreate goals for theclients ITPProgress toward theITP goals aredocumented in theclients progress notesThe progress noteshelp assess the client’sprogress whenevaluating the goalson the ITP-ROn-going needsidentified on the ITP-Rare incorporated intothe MHA-Update
Definition: Medical Necessity“An LPHA has determined through assessment that a client has adiagnosis of mental illness or serious emotional disorder as defined inthe ICD-9-CM or DSM-IV that has resulted in a significantimpairment in the clients level of functioning in at leastone major life functional area and needs one or moremental health services that are identified in the Mental HealthAssessment and ITP to stabilize the clients functioning, or torestore or rehabilitate the client to a maximum level oflife functioning...” (Rule 132)Reference: IL Medicaid Rule 132- http://www.ilga.gov/commission/jcar/admincode/059/059001320A00250R.html
Service Documentation Process-Progress Notes• Functions as receipt for services• Enables communication between members of the treatmentteam when there is more than one JCFS staff involved in thecase• Timely completion and submission is critical• Helps document progress or lack of progress on an on-goingbasis to be able to evaluate the goals for ITP-R• All documentation should demonstrate the treatment theclient is receiving for their mental health needs
Progress Notes• Remember-All services thatare necessary and therapeuticmay not be Medicaid Eligible
Part 132 Service Documentation(Progress Notes/Case Notes)• What is needed on ALL Service Documentation (progressnotes)– Client Name– Name of Service– Date of Service– Start Time & End Time/Duration of service– Specific on or off site location– ITP goal– Signature of staff who provided service– Credential of staff who provided service
•1 to 7 minutes = Not Billable•7 ½ to 22 minutes = 1 unit•23 to 37 minutes = 2 units•38 to 52 minutes = 3 units•53 to 67 minutes = 4 units•68 to 82 minutes = 5 units•83 to 97 minutes = 6 units•98 to 112 minutes = 7 unitsCalculating Units of Service
Progress Note Helpful Reminders• Include staff intervention – (“I” statements) and client response (“he/she”statements)• Progress statements should include a definitive evaluation of a specificgoal with an explanation on how you reached that evaluation• Ensure that a service note exists for every unit billed• Be cautious about the amount of time indicated – was the serviceprovided the entire time?• Each note must reflect that the writer knows the client’s ITP goals• Travel and documentation are not reimbursable services under Part 132• Only document one service per note
Part 132 Service DocumentationS I R P• Service Narrative Elements– Description of Service Situation– Staff member’s Intervention– Client’s Response to Intervention (except Case Management services)– Progress toward ITP goals (except Case Management services, MHA andITP development/review/modification)
Situation• Situation should be the first sentence of the narrative• Should document the purpose of the interaction(situation) or what you identified as the issue thatneeded mental health intervention• It should demonstrate the type of service we arebilling for
SituationExamples of appropriate S statements:• “I met with Rodney for our weekly individual therapy session”• “I met with the clients to conduct our weekly AngerManagement Group”.• “John seemed upset so I took a moment to explore what maybe bothering him.”• “Keisha struggled to respond appropriately when she gotupset with a peer so I asked to speak with her in her room.”• “Lisa ran from placement today so staff John Smith and I metto review what led to her struggles.”• “I took the client to the local McDonalds to help him practiceappropriate social interactions with strangers.”
Intervention• Must clearly and specifically define what the interventionwas:• What was the type and purpose of the specific mental healthintervention used?• What exactly did you say and/or do?– Prompting and praising are not interventions by themselves-need torelate to mental health needs– “Processing” has to specifically describe what you said• What actions did you do to help address the client’s mental healthneeds?
What is an Intervention?• What skills did I teach, model, cue, or encourage in this intervention or what discussiondid I guide, assess, facilitate or encourage?• Focus of intervention needs to be on teaching or assisting, not “doing for” the client• Intervention needs to be active: listening or being present is not an intervention• Why am I providing this service?• How does it relate to the client’s mental health needs?• Why was the service necessary to help in the recovery process?• What is it about the client’s illness that prevents him/her from performing this activityon his/her own?• How is this service different for this client when compared to developmentally appropriate needs?• What makes your skills/knowledge necessary to help the client?• How is what I am doing with the client any different than what his/her neighbor, family member, orother helpful person might do for/with him/her?• Why did this activity require the intervention of a mental health professional?
Interventions• Examples of appropriate I statements:– “I encouraged the client to describe what happened at school with hispeer that led to the verbal altercation.”– “I explored the reasons the client has been feeling “down” lately.”– “I demonstrated for the client how to speak with the cashier tohighlight appropriate social interactions.”– “I inquired about the client’s recent home visit to explore how she wasable to manage her feelings when her sisters frustrated her.”– “I reviewed the client’s safety plan to help engage her in making moreappropriate decisions.”
Response• Must clearly and specifically state what the client’s responsewas to each intervention(can be both behavioral and whatthey said, but it has to be specific)• Although quotes are not needed, there does need to be alevel of detail to determine whether the intervention waseffective or not.• For Case management services, response is focused on whatthe contact told you, not on the client’s response
ResponseExamples of appropriate R statements:Specific:– Non compliant: “client stated he had a bad day at school”• Compliant: “Client stated that he had a bad day at school becausethe teacher yelled at him and he left the class without permission.”– Non compliant: “client became angry”• Compliant: “Client became angry and stated that his peer was astupid idiot and he was going to punch him.”Other examples:• Client smiled and agreed with my statement.• Client refused to respond to my question.• Client balled up his fist and appeared more upset by our discussion.• Client became quiet and seemed to be thinking about what wassaid.
Progress• Progress statements are usually the last sentence of the note• Progress statements are not needed for Mental HealthAssessment, Treatment Plan Development, Modification andReview or Case management Services (Client CenteredConsultation, Mental Health, or Transition, Linkage andAftercare• Progress statements are subjective- they are your opinion ofwhether or not the client made progress
ProgressProgress statements should use the format:• “client made rating statement progress today in hergoal of the ITP goal related to the service orintervention because she summary of whatever shedid or didn’t do related to the progress rating”• “due to whatever the behavior or issue was, clientshowed progress rating in his goal of whatever hisITP goal was related to the service or intervention”
ProgressExamples of appropriate P statements:• “Kara made minimal progress in her treatment goalof avoiding self harming behavior as she continuedto cut herself with a paper clip when she wasupset”.• “Andrew made significant progress on histreatment goal of express his anger proactively bydiscussing a situation that was frustrating him inorder to develop healthy solutions instead offighting.”
Medicaid Billing/Narratives-Things to Remember• Don’t use a diagnosis as a label or a constant reminder to the client• Focus on STRENGTHS in your services, as well as in your writing• Notes should reflect how you provided services to assist with theclient’s mental health needs• Accurately reflect the time (to avoid overlap billing)• Some services should be documented but will not be billable.• The services should focus on the client’s mental health, not justbehaviors. And behaviors being focused on need to match theclient’s diagnosis.• Progress statements should related to what is happening in theservice not what led up to the service.
Medicaid Billing/Narratives-Things to Remember• Use respectful language when describing race, gender, age,sexuality, mental health and physical condition• Avoid judgmental terms• “Lazy” is judgmental, “unmotivated” is not• “Foul mouthed” is judgmental, “uses profanity” is not• “Just sits there” is judgmental, “passive” is not• “Obnoxious” is judgmental, “oppositional” is not• “Liar” is judgmental, “not telling the truth” is not• “Stupid” is judgmental, “unable to comprehend” is not• “Slob” is judgmental, “uninterested in appearance” is not• “Nasty” is judgmental, “poor hygiene” is not
ACTION WORDSTime to create a list of action words to use in your progress notes
APPROVED SERVICESJCFS approved Medicaid Services available to programs
Approved Mental Health Services• JCFS approved Medicaid Eligible Services– Mental Health Assessment– Treatment Plan Development, Review and Modification– Therapy/Counseling-Individual, Group and Family– Community Support-Individual, Group and Residential (individual andgroup)– Case management-Mental Health– Case management-Client Centered Consultation– Case management-Transition, Linkage and Aftercare– Crisis Intervention– Psychotropic Medication Administration, Training and Monitoring– RESPITE-Community Support Only
Medicaid Part 132 Services:Mental Health Assessment• Formal process of gathering information regarding:– clients mental and physical status and presenting problems– identification of mental health service needs– recommendations for service delivery• Contact to complete assessment with the client and/or collaterals(when appropriate) is required• Details of what information was gathered during that specific service• Minimum of an MHP to bill for this service• This is not process of the information but instead focused on obtainingthe information to help understand the client.
Mental Health AssessmentService Documentation Exercise- What’s missing from this note?Met with client for the purpose of gaining information for theassessment. Client was cooperative and seemed to have littledifficulty talking in this session. Plan is to meet next week tocontinue gathering information from client.
Mental Health Assessment-Compliant NoteI met with client for the purpose of gathering information for the assessment.Client was cooperative and seemed to have little difficulty talking in thissession. Client and I discussed the resources she has available to her. Shesaid that she and her mom regularly go to church and she views religion tobe an important part of her life. I asked her about the things she likes to dofor fun. She said she really likes quiet, low key, activities such as reading andwriting poetry, but she also enjoys sports with her best friend. I then probedfor further information about her previous placements. The client spendsome time discussion each of her previous placement. We planned onmeeting next week to continue gathering information from client for thepurpose of developing the mental health assessment.
Medicaid Part 132 Services:Treatment Plan Development, Review and Modification• Development of a plan (goals and objectives) to deliver specificmental health services• Contact with the client and/or collaterals (when appropriate)to complete ITP is required• Treatment team meetings to develop/review plan are billable ifrelated directly to the ITP and not just overall progress inservices• Discussion related to developing goals/objectives or reviewingentire plan• A minimum of an MHP is needed to provide this service
Service Documentation Exercise- What’s missing from this note?Treatment Plan Development, Reviewand ModificationTim told me he knew he needed to stop hitting people when he is mad. Iagreed that he needed to learn to manage his anger. Tim and I alsodiscussed things he could do when he feels like lashing out. He said that helikes listening to music and it seems to calm him down. He agreed to carryhis iPod with him and, at least for now, listen to his music when he feels likehe’s starting to lose control. He also said that he really enjoys hitting golfballs in his yard and that would be a good thing for him to do when he’s athome and feeling frustrated or upset. I agreed to talk to the team about hisideas.
Compliant Note:Treatment Plan Development, Reviewand ModificationToday I met with Tim for the purpose of treatment planning. I asked Tim what hethought his goals of treatment were and what he thought he needed to focus on.Tim said he knew he needed to stop hitting people when he is mad. I agreed thathe needed to learn to manage his anger. Tim and I worked together to come upwith his first treatment goal around anger management. Tim and I also discussedthings he could do when he feels like lashing out. He said that he likes listening tomusic and it seems to calm him down. He agreed to carry his iPod with him and, atleast for now, listen to his music when he feels like he’s starting to lose control. Healso said that he really enjoys hitting golf balls in his yard and that would be a goodthing for him to do when he’s at home and feeling frustrated or upset. Tim activelyengaged in his treatment planning and I agreed to talk to the team about his ideasso they could be included in his ITP.
Medicaid Part 132 Services:Therapy/Counseling• Is used to promote emotional, cognitive, behavioral orpsychological changes• intervention utilizes psychotherapy theory and techniques.• Individual, Group and Family modalities are allowed• Staff must provide psychotherapy intervention related to ITP• More in-depth evaluation and treatment of mental health issues• Usually scheduled appointments with the client• Does not include “check-in meetings” or rapport building alone.• Minimum of an MHP is needed to provide this service
Medicaid Part 132 Services:Therapy/Counseling• Group Therapy/Counseling documentation must also include:– Group topic– Group interactions– Psychotherapy intervention provided– Group’s response– Individual client’s response– Individual client’s progress in group• Group Therapy/Counseling must directly relate to the client’smental health needs specifically
Counseling/TherapyService Documentation Exercise- What’s missing from this note?• Individual Therapy/CounselingTim and this therapist met for an individual therapy session. Tim has been havingproblems getting along with peers lately and has had a “shorter fuse” lately. Timacknowledged being angry at one of his roommates because he is always throwinghis dirty clothes on the floor and is not interested in helping to keep the room pickedup and clean. Because of this, Tim and his roommates can never get the “cleanestroom in the program” award and this makes Tim mad. Tim agreed that his behaviorshad improved since he first came to the program, but stood firm on his position thatthe peer was “wrong to mess it up for the rest of us”. Tim was agitated today and willcontinue to discuss this issue in future sessions.
Counseling/Therapy-Compliant Note:Tim and this therapist met for an individual therapy session. Tim has been having problemsgetting along with peers and has had a “shorter fuse” lately. I asked Tim if he can recall a timerecently where he was upset. Tim acknowledged being angry at one of his roommatesbecause he is always throwing his dirty clothes on the floor and is not interested in helping tokeep the room picked up and clean. Because of this, Tim and his roommates can never get the“cleanest room in the program” award and this makes Tim mad. I acknowledged his feelingsof anger toward the situation and asked him how he felt before he became angry. Tim saidthat he felt like “he couldn’t do anything about it.” I guided Tim in identifying other times inhis life that he has felt this way. Tim said that he felt this way when his mother left him. Wediscussed how feeling helpless can often lead to feelings of anger and that those feelingscould be trigged by current events that reminded us of past events. Tim said that madesense, but stood firm on his position that the peer was “wrong to mess it up for the rest of us”.Tim was agitated today and will continue to discuss this issue in future sessions. Because Timagreed that “triggers” made sense, I feel he is making some progress towards understandinganger and meeting his anger management goal.
Medicaid Part 132 Services:Community Support• Assist clients to achieve and maintain rehabilitative, resiliency and recovery goals• Therapeutic interventions that facilitate illness self-management, skill building,identification and use of natural supports, and use of community resources• Services WITH the client• Community Support Residential – includes group or individual interventionsprovided at the residential site (on site)• Community Support – includes group or individual interventions provided in thecommunity• Staff must provide therapeutic intervention related to ITP goals• Can include services provided to family on behalf of the client or to assist with theclient’s mental health needs– Praising/prompting client alone is not Community Support– Content vs. Context – Routine activities (shopping, hygiene, meals, meetings) do not equalCommunity Support– Custodial task for Residential-services for the routine care of the youth.
Medicaid Part 132 Services:Community Support• Allowable activities:– Helping client identify individual strengths, resources, preferences andchoices– Helping client identify and/or utilize existing natural supports or developingadditional support that could become part of the client’s natural supportteam– Helping client develop a crisis management plan for mental health issues– Helping identify or address risk factors related to relapse/mental healthsetbacks and development of relapse prevention plans and strategies– Supporting and encouraging client with self-advocacy and participation indecision making, treatment and treatment planning– Support and consultation to the client or his/her support system that isdirected primarily to the well-being and benefit of the client– Skill building in order to assist the client in the development of functional,interpersonal, family, coping and community living skills that are negativelyimpacted by the clients mental illness
Sample Activities-When they relate toMental Health Needs• Processing a difficult day, a recent change, a negative choice• Identifying and discussing recent progress in treatment• Practicing social skills in a “nature environment”• Creating tools the client can use when they are upset• Exploring support options in their community• Supporting client while they are discussing concerns withothers
Community Support-Residential IndividualService Documentation Exercise-What is missing from this note?Today, Jessica completed her chores with minimal prompting.Chores usually set this kid off and the typical response is “I don’tfeel like cleaning.” Today was different, she complied without anyproblems. I discussed how her normal lack of motivation canimpact her future (job, school, transitioning to another level ofplacement, etc.) Jessica responded well and was able tounderstand how her behaviors can affect her feelings and future.This is progress for Jessica on her goal to follow programexpectations because she did not need repeated prompts.
Community Support-Compliant NoteToday, Jessica completed her chores with minimal prompting. Chores usually “setthis client off” and the typical response is “I don’t feel like cleaning.” Today wasdifferent, she complied without any problems. I took this moment to explorewith the client what if felt like to accomplish something and how this canbenefit her in the future. I encouraged her to describe how she felt bysuccessfully completing the task and not have staff “get on her case.” The clientresponded with a smile and said it is much easier to not hear staff voiceconstantly. I explained that when she feels unmotivated or uninterested indoing something she should think back to this good feeling. The client agreedthat this may help her when she feels down or uninterested in things. I thenexplored with the client how not completing things can impact her future (job,school, transitioning to another level of placement, etc.) Jessica responded welland was able to understand how her behaviors can affect her feelings and futurebut said sometimes she just doesn’t feel like doing something. I again remindedher to think about this success. . This is progress for Jessica on her goal tounderstand the impact of her mental health needs on her ability to beaccomplish her goals because she was able to explore what it takes to feelsuccessful.
Medicaid Part 132 Services:Case Management – Mental Health• Identification, organization, coordination and advocacy services forclients• Due to mental health needs the clients need help accessing servicesincluding: mental health, substance abuse, social, vocational,educational, housing, public income entitlements and othercommunity services to assist the client in the community• Assisting clients in obtaining services outside the agency, includingany application process needed to obtain those services• Identifying and investigating available resources• Explaining options to the client
Medicaid Part 132 Services:Case Management - Client-Centered Consultation• individual client-focused professional communications• provider staff, or staff of other agencies, or other collateral contacts• participants are involved with providing services to a client• Must be focused on discussion of mental health issues, support, progress, goals,etc.• A meeting, phone call or conference for professional communication• Client or family may be present in the meeting, but the focus of the meeting isprofessional communication• Direct mental health interventions with the client are not allowable• Discussion of behavioral concerns are not Medicaid eligible• “Shift change” review of clients’ day/activities are not billable
Medicaid Part 132 Services:Case Management – Transition Linkage & Aftercare• assist in an effective transition in living arrangements consistentwith the client’s welfare and development• Assisting clients in transitioning to a new placement (does notinclude progressing the transition)• Time spent planning for discharge with staff or foster parents(logistics)• Coordinating pre-placement or post-placement visits• Discharge staffings• Working with others to establish after care plan
Case Management-Client CenteredConsultationService Documentation Exercise: What is missing from thisnote?I met with Child Care Worker John Smith to discuss the client’scurrent AWOL status. We discussed what we could do to helpthe client remain in the program if she was to return thisevening. We decided the best plan was to offer her support andencouragement. We would also remind her of her desire tocomplete the program quickly.
Case Management-Client CenteredConsultationCompliant Note:I met with Child Care Worker John Smith to discuss the client’s current AWOLstatus. I started out explaining that the client had seemed upset after aphone call. John indicated this was a pattern for the client because shestruggled to manage her feelings when someone upsets her. He explainedher usual way to cope is to run so she does not have to deal with herfeelings. We discussed what we could do to help the client remain in theprogram if she was to return this evening. I suggested that we provide somealternative ideas on ways to cope when she gets upset or does not knowwhat to do. We identified journaling, listening to music, or asking for a passto go for a walk as some possible ideas to deal with her feelings. We decidedthe best plan was to offer these suggestions and support and encouragementher to use them when we see that she seems upset.
Medicaid Part 132 Services:Crisis Intervention• Activities to stabilize a client in a psychiatric crisis• Immediate symptom reduction, stabilization and restoration to aprevious level of role functioning• Must include one of the following:– deterioration in client’s level of role functioning-client is doingsignificantly worse– an increase in acute symptomatology-psychological decline– threat to client’s safety or functioning-specifically the possibility ofremoval from family or the community (i.e. psychiatric hospitalization)• It is not behavioral crisis only-fighting, restraints, running away,issues requiring police intervention• It is not “Frantic concerns” from family/foster parents about on-going clinical issues
Service Documentation Exercise- What’smissing from this note?The client needed crisis intervention services due to threatening to harm staff andpeers. I asked the client to “come to his room and talk about whats going on" but herefused stating "you cant tell me what to do, I can do whatever I want to do". Itelephoned the on-call supervisor to see if SASS could be called. I informed thesupervisor that the client has an active plan to harm a peer, committed two assaultsagainst staff yesterday, and has reported that he has other weapons he plans to useagainst a peer. The supervisor indicated because of the client’s current and pastmental illness concerns SASS would be called. While waiting for SASS to arrive, Icollected the clients individual treatment plan, individual behavior support plan, andhis mental health assessment. SASS arrived within ten minutes and I provided thesame information to him. The SASS worker, the client, and I met and discussed hisrecent behavior. The client reported that he "hasnt decided whether or not to start ariot" and would not contract for safety. I showed the SASS worker a very large piece ofconcrete that the client has brought to the building to harm his therapist. SASSdetermined that the client needed to be admitted to hospital due to his active plan toharm others. I will inform the treatment team of the client’s admission to hospital.
Compliant Note: Crisis Intervention5:00-6:00 pmThe client needed crisis intervention services due to threatening to harm staff and peers. Child CareWorker John Smith informed me that the client had a weapon in his pocket and threatened to kill apeer tonight while he is sleeping. I asked the client to “come to his room and talk about whats goingon" but he refused stating "you cant tell me what to do, I can do whatever I want to do.” I telephonedthe on-call supervisor to see if SASS could be called. The on-call supervisor asked questions to assessthe client’s mental health needs to determine the level of deterioration and what level of interventionwould be needed. I informed the supervisor that the client has an active plan to harm a peer,committed two assaults against staff yesterday, and has reported that he has other weapons he plans touse against a peer. The supervisor indicated because of the client’s current level of crisis and significantconcerns for his mental health stability, SASS would be called. Child Care Work John Smith continuedto monitor client while waited for SASS to arrive. Client continued to make threats and seemed to bebecoming even more out of control. While staff was with the client and I was waiting for SASS toarrive, I collected the information SASS would need to further assess the clients needs including theclients individual treatment plan, individual behavior support plan, and his mental health assessment.SASS arrived within ten minutes and I provided the same information to him. The SASS worker, theclient, and I met and discussed his recent behavior and to assess his current risk and his ability to besafe in residential placement. The client reported that he "hasnt decided whether or not to start ariot" and would not contract for safety. I showed the SASS worker a very large piece of concrete that theclient has brought to the building to harm his therapist. SASS determined that the client needed to beadmitted to hospital due to his active plan to harm others. The client was transported to the hospitalfor admission. I went with to assist with the admission process. I will inform the treatment team ofthe client’s admission to hospital upon return to the house.
YOUR TURNHow would you provide a Medicaid service and document it for thefollowing situations?
Case Example 1:Client Treatment Plan includes:• Client will behave appropriately when she feels she is being provoked.• Client will be able to stop and think before reacting situations thatupset her.• Client will demonstrate healthy ways of managing her feelings.Client comes home from school and reports she wassuspended from school for cursing at her teacher andthrowing her books across the room.
Case Example 2:Client Treatment Plan includes:• Client will manage his feelings in an appropriate way.• Client will seek assistance if he feels he cannot manage his feelingssafely.• Client will become more involved with activities he enjoys.You discover small cuts on the client’s arm while he iseating dinner. You notice a small, sharp object layingnext to his plate. The client has a history of engaging inself-harming behavior.
Case Example 3:Client Treatment Plan includes:• Client will demonstrate healthy ways of managing her feelings.• Client will understand and be able to recognize when her mood ischanging in order to manage her behaviors appropriately.• Client will develop a safety plan to manage her symptoms of mania.Client comes home from being AWOL. She reports shejust came home to change her clothes and getsomething to eat and then she is leaving again.
Compliant Note-4:00 pm-5:15 pmCommunity Support-Residential GroupGroup Note• The group participated in the weekly scheduled group session. I engaged them in arelationship activity. The purpose of the group was to explore attitudes, values, andbeliefs about relationships by answering the questions on the cards. I explained to thegroup that many of these questions focus on intimate or dating relationships whilesome apply to friendships, family ad other types of relationships. I asked each client topull a card and answer the questions from their point of view and other clients weregiven the opportunity to share their thoughts. I encouraged them to expand on theirideas when they seemed reluctant to share. I observed the group membersrespectfully listen to each others thoughts and opinions. The group also did a good jobinteracting with each other.Client Note• Client was able to participate in the planned activity and did a fair job interacting withthe group members. During the activity the client was asked to share her thoughtsabout healthy and unhealthy relationships. The client did a good job explaining havingthe ability to talk about your relationship with her partner is a sign of a healthyrelationship. The client respectfully discussed her thoughts with her peers. I challengedthe client to continue to focus on these ideas in her current relationships. The clientmade fair progress toward her goal of improving her interpersonal skill by activelyparticipating in the planned group activity and demonstrating an understanding of whatit takes to build a healthy relationship.
Compliant Note-Community Support Residential-IndividualThe client asked me if she could talk to me about something that wasbothering her. We sat down to talk and she told me that she was upset thather peer had started a fight with her in the morning. I asked her whathappened from her point of view and she told me that the peer was makingrude comments to her and calling her names. I explored with the client howthis made her feel and she told me that it hurt her feelings and she did notdeserve to be called mean names. I offered to help the client think of waysthat she could try and ignore this behavior and not let it ruin her mood. I toldher that sometimes it helps me to just tell the person that your feelings arebeing hurt or just walk away and deep breaths. She also mentioned that shelikes to put her feelings into songs and sing them when she has calmed down.I then encouraged her to think of ways to approach her peer about herfeelings when she is ready. The client said that she did not want to thinkabout that step until she felt better. The client made progress towards goal ofexpressing her feelings appropriately because she discussed her concernswith me instead of fighting her peer.
Compliant Note-Case Management-Mental Health“I took the client to the local high school to register her forclasses. I spoke with the intake coordinator, providing thecoordinator with the required documentation to completethe enrollment. The coordinator reviewed the paperworkand determine that client would need to be enrolled as asophomore. I inquired about their summer school programand graduation requirements. The coordinator provided theclient and myself with all the requested information. I thenexplored what additional resources would be available ifthe client need additional help to get caught up. Thecoordinator indicated that tutoring was available and theclient should also ask her teachers for help. We finished upthe discussion reviewing the schools policies.”