RIDGEVIEW RANCH
Documentation Training
Importance of Good Documentation
 Improves quality of care
 Reduces risk
 Meets legal requirements
 Protects during instances of
litigation
Documentation According to CARF
An interpretive summary is required after each
assessment.
 An “interpretive summary is a paragraph or
paragraphs written to integrate and interpret from a
broader perspective all history and assessment
information collected. It should identify co-occurring
disabilities and address how they are considered when
developing the individual plan.” CARF Standards Manual
Interpretive Summary
 Central theme(s) apparent by the presentation of the
person served.
 Histories (family, cultural, marital, work) and
assessments (medical, psychosocial, spiritual, vocational,
etc.) with special emphasis on potential interrelationships between sets of findings.
 Mental Status
 The perception of the person served of his/her
strengths, needs, aptitudes, preferences, stage of change,
limitations and problems.
Interpretive Summary: cont’d
 Clinical judgments regarding both positive and negative
factors likely to affect the person’s course of treatment
and clinical outcomes after discharge (i.e. recovery).
 GAF/Level of Functioning
 Recommend treatments, including any further/special
assessments, tests, etc., as well as routine procedures (e.g.
laboratory tests).
 A general discussion of the anticipated level of care,
length and intensity of treatment, and expected focus
(goals) with recommendations.
Sample Interpretive Summary
Michael has become an excessive worrier over the past 6 months
and majority of his day is spent worrying which causes tension,
high level of distraction, irritation and restlessness. Being on edge
sometimes leaves him fatigued and mildly depressed. Michael’s
worrying is probably coming from unresolved issues regarding his
marital problems, his mother’s death and legal issues resulting
from his overspending on friends in his desire to be accepted and
have friends. Perhaps Michael is also processing normal daily
happenings in negative ways. He desires treatment and appears to
be in the preparation stage of change.
Sample Interpretive Summary: cont’d
Diagnosis
I 300.00 Anxiety Disorder NOS
II none
III none
IV Problems with primary support group,
occupational problem, legal problem
V 60
Plans
 The plan is developed with the active participation of the
person served.
 The plan:
 is prepared using the information from the assessment
process.
 is based on the needs and desires of the person served
and focuses on the person’s integration and inclusion
into:




the local community,
the family, when appropriate,
natural support systems and
other needed services
Plans
 The plan:
 involves the family/legal guardian of the person served,
when applicable or permitted.
 identifies any needs beyond the scope of the program.
 specifies the services to be provided by the program.
 specifies referrals for additional services.
 is communicated to the person served in a manner that
is understandable.
 when possible, is provided to the person served.
Plans
 The plan includes the following elements:
 Goals that are:
 expressed in the words of the person served.




Examples:
“I want to find a job.”
“I want to get my degree.”
“I want to get my anger under control.”
 reflective of the informed choice of the person
served or parent/guardian.
 appropriate to the person’s culture.
 appropriate to the person’s age.
Plans
 Goals that are:
 based on the person’s:




Strengths.
Needs.
Abilities.
Preferences.
 Specific service or treatment objectives that are:
Reflective of the expectations of:
 (a)The person served.
 (b)The treatment team.
Reflective of the person’s age.
Reflective of the person’s development.
Reflective of the person’s culture and ethnicity.
Plans
 Specific service or treatment objectives that are:
 Responsive to the person’s disabilities/disorders or
concerns.
 Understandable to the person served.
 Measurable.
 Achievable.
 Time specific.
 Appropriate to the treatment setting.
 Examples:
 “I will start anger management counseling after my first week in the
program and complete the counseling by discharge.”
 “I will be provided with job coaching and will try to get a job by
10/31/13.”
Plans
 The plan contains:
 Identification of specific treatment
interventions to be used.
 Frequency of specific treatment interventions.
 When applicable, information on, or conditions
for:
 Transition to other community services.
 Community-based service options that are available
for persons in long-term residential support
programs.
 When applicable, identification of:
 Legal requirements.
 Legally imposed fees.
Plans
 When applicable, a personal safety plan,
completed as soon as possible after admission,
that identifies the following:
 Triggers, including assessment of the risk for
dangerous behaviors.
 Current coping skills.
 Warning signs.
 Preferred interventions.
 Advance directives, when available and indicated.
Plans
 When the person served has co-occurring disabilities and/or
disorders:
 The individual plan specifically addresses those issues in an
integrated manner.
 Services are provided by personnel, either within the
organization or by referral, who are qualified to provide
services for persons with co-occurring disabilities and/or
disorders.
 If residential services are provided to persons who are
medically fragile:
 The individual plan specifically addresses how services will be
provided in a manner that ensures the safety of the person
served.
 Services are provided by skilled healthcare providers.
 Services are provided in accordance with all regulatory
requirements.
Progress Notes
 Progress notes:
 Are:
 Signed.
 Dated.
 Document:
 Progress toward achievement of identified:
 Objectives.
 Goals.
 Significant events or changes in the life of the person
served.
 Movement to other levels of care.
 Are timely.
Progress Notes
 Examples:
 “John had his first anger management session today and
did a good job of recognizing triggers for his outbursts.”
 “Beverly met with her job coach today and noted that
she ‘really got a lot out of the vocational exploration
exercise’ she went through.”
 “Cherie reported that she had been informed that her
great aunt passed away yesterday. Staff were alerted to
watch her closely over the next few days.”
Transition Plan
 Transition plan:
Is developed with the input and participation of:






The person served.
The family/legal guardian, when applicable or permitted.
A legally authorized representative, when appropriate.
Personnel.
The referral source, when appropriate and permitted.
Other community services, when appropriate and permitted.
Identifies the person’s current:
 Progress in his or her own recovery or move toward wellbeing.
 Gains achieved during program participation.
Transition Plan
 Transition plan:
Identifies the person’s need for support systems or
other types of services that will assist in continuing his
or her recovery, well-being, or community integration.
Includes information on the person’s medication(s),
when applicable.
Includes referral source information, such as contact
name, telephone number, locations, hours, and days of
services, when applicable.
Includes communication of information on options
available if symptoms recur or additional services are
needed, when applicable.
Discharge Summary
 For all persons leaving services, a written discharge
summary is prepared to ensure that the person served
has documented treatment episodes and results of
treatment. The discharge summary:
Includes the date of admission.
Describes the services provided.
Identifies the presenting condition.
Discharge Summary
 Describes the extent to which established goals and
objectives were achieved.
 Describes the reasons for discharge.
 Identifies the status of the person served at last
contact.
 Lists recommendations for services or supports.
 Includes the date of discharge from the program.
Questions?