4 hours documentation


Published on

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.

Published in: Health & Medicine
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

4 hours documentation

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