Documentation for Mental Health
Disorders
October 2011
Introduction to Harvest Healthcare
 Experience. Education. Excellence.
 Harvest is a leading full-service behavioral health provider,
specializing in the delivery of progressive and innovative
consultative behavioral health services for patients and
residents residing in skilled nursing, rehabilitation, and
assisted living facilities. Our multidisciplinary team of highly
skilled professionals work together to offer a broad menu of
services including but not limited to 24-hour prescriber oncall services and hospitalization support, comprehensive
cognitive assessments, documentation review, OBRA
compliance support and customized educational programs
designed for the individual needs of your facility.
Objectives
 This presentation on documentation was developed for the
continuing education of healthcare providers.
 At the conclusion of this presentation, participants will have a
basic understanding of documentation of mental health issues
in long term care facilities.
 Mental health professionals should be consulted for
management of patients with mental health issues.
Why
do
we
document?
The common answers are to prove we did something or to protect our professional
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decisions.
 The real reason for documentation is to promote quality and coordination of care. In the
end, the documentation that is produced may be used for accreditation and licensing,
performance improvement, peer review, reimbursement, and legal protection.
 There are many organizations that set standards or have requirements related to
documentation:
 The Centers for Medicare & Medicaid Services (CMS) and the MDS 3.0 is only one
standard.
Others include:
• CMS/federal certification
• State survey agencies—licensure
• Professional practice acts (state specific) such as RN, LPN/LVN, PT, PTA, OT,OTA, SLP
• Accreditation organizations (i.e., The Joint Commission)
• Professional associations: American Nurses Association, American Medical Directors, Association,
American Physical Therapy Association, The American Occupational Therapy Association, Inc., and
American Speech-Language-Hearing Association
• American Health Information Management Association
• Insurance carriers (i.e., liability and workers compensations)
• Payers (e.g., Medicare, Medicaid, Medicare Advantage, Insurance, Veterans Affairs [VA])
• Medicare A/B MAC (former Fiscal Intermediaries)
Documentation by inclusion or
exception
 In the clinical setting (long-term care [LTC]) clinical
documentation is done by inclusion and/or exception.
 Documentation by inclusion is done on an ongoing, regular
basis and makes note of all assessment findings,
interventions, and resident outcomes.
 Documentation by exception makes note of negative findings
and is completed when assessment findings, interventions, or
resident outcomes vary from the established assessment
norms or standards of care.
Charting by inclusion and exception
 Charting by exception replaces the long held belief of “if it
was not charted, then it was not done” with a new premise,
“all standards have been met with a normal or expected
response unless documented otherwise.”
 Documentation by inclusion in the skilled nursing facility
(SNF) includes: weekly/monthly summaries, routine vital
signs, weights, target behavior monitoring, MAR/TAR, etc.
 Documentation by exception in the SNF could include: falls,
skin tears, pressure ulcers, pain, change in mood/behavior,
weight loss, change in vital signs, change in cognitive status,
etc.
Documentation for Assessment &
Planning
 In clinical contexts, clear and comprehensive documentation
of all case-related facts and circumstances is essential.
 Careful and thoughtful information collection ensures that
practitioners have an adequate foundation for their clinical
reasoning and intervention plans.
 In addition, the data provide a reliable source of measuring
performance and outcomes.
 Incomplete records may lead to inadequate planning and
intervention, critical judgment errors, and poor outcomes
for clients.
Documentation for Service Delivery
 Comprehensive records are necessary for competent
delivery of clinical, community-based, and agencybased services and interventions.
 Thorough documentation provides a solid foundation
for practitioners' efforts to design and deliver highquality services, whether they involve clinical
intervention, supervision, or agency administrators'
management and evaluation of personnel and
programs.
Continuity and Coordination of Services
 Documentation facilitates professional and
interdisciplinary collaboration and coordination of
services.
• In clinical settings, documentation ensures that staff
members have up-to-date details concerning clients'
needs.
• Administrative records facilitate coordination among
supervisors, managers, and administrators in programs
and agencies.
Risk Management
 Risk management is the identification, assessment, and
prioritization of risks followed by coordinated and
economical application of resources to minimize, monitor,
and control the probability and/or impact of unfortunate
events or to maximize the realization of opportunities.
 Risk-management guidelines related to documentation and
case recording can be placed into four conceptually distinct
categories:
1) the content of documentation
2) language and terminology
3) credibility
4) access to records and documents
Language and Terminology
 Wording in documentation is just as important as the
substance of the content.
 Loose and casual language and terminology can be
catastrophic to the client, practitioner, supervisor, and
agency.
 Practitioners must choose their words carefully, taking care
to be clear, to fully support conclusions drawn, to avoid
defamatory language, and to write knowing there is always an
audience.
The importance of clarity
 Practitioners should use clear, specific, unambiguous, and precise
wording. Lack of clarity, specificity, and precision provides
considerable opportunity for adversarial parties to raise doubts about
practitioners' claims, observations, and interpretations.
 Conversely, clear, specific, unambiguous, and precise wording
enhances the delivery of services and strengthens practitioners' ability
to explain and defend prior decisions and actions.
 Avoid the use of professional jargon, slang, or abbreviations that may
be misunderstood.
 For example, the abbreviation "DD" could mean dual diagnosis or
developmental disability. The abbreviation "BPD" could mean bipolar
disorder or borderline personality disorder. "SA" could mean substance
abuse or sexual assault. Such ambiguity could prove disastrous if the
abbreviations are misinterpreted by a colleague or debated in an ethics
hearing, licensing board inquiry, or litigation.
Documentation Review Questions
 Clinical note: Is the content and intent of the documentation
clear?
• Does the note show compliance with the care plan including
continuity and consistency?
• How does the clinical note show cooperation and collaboration?
• Is there congruence or contradiction within the documentation?
• Does the note identify change?
• Are resident comments identified as comments?
Tips for Accurate Documentation
• Document concisely and factually, using precise language and
specific behaviors
• Start each entry with the date and time
• Do not offer your opinions discuss observations (i.e., resident
slept poorly vs. resident up walking in hall six times between 3
a.m. and 5 a.m.)
• Do not repeat information that is stated elsewhere in the health
record, such as on a flow sheet
Mental Health Documentation
 Documentation for mental health issues include the
following:
 Psychiatric Assessment (completed by psychiatric consultants)
 Mental Health Progress Notes by LCSW & Psychologist
 Cognitive Assessments by Psychologists
 Physicians order sheet
 Nursing notes
 Medication Administration Record (MAR)
 Behavior tracking record
 PRN medication
 CNA behavior flow /tracking sheet
Psychiatric Assessment
 The psychiatric assessment from Harvest Healthcare will be
located in the psychiatric section of the paper chart for each
individual patient.
 It will include the identified problem/problem behaviors,
diagnosis and the treatment recommendation(s).
 If a cognitive assessment or psychotherapy has been
recommended, the corresponding paperwork for these will
also be located in the psychiatric section of the chart.
Physicians Orders
 Once a mental health diagnosis has been made, the diagnosis
will be on the order sheet.
 Medications for mental health issues will be found on the
order sheet as well as the reasons the medication has been
ordered.
• i.e. zoloft 25mg one po daily for depression
•
Labs and other assessments required for specific medications also
need to be added to the order sheet
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i.e. AIMS every six months for antipsychotics
Orthostatic bp checks monthly secondary to Seroquel use
Nursing Notes
 Each long term care facility has methods for documenting
nursing notes (electronic/paper/ daily/weekly/monthly
assessments) driven by credentialing bodies, payer source, level
of care, etc.
 For the purpose of this presentation: Nursing notes should
follow the SOAP format.
 S: subjective findings regarding the mental health issue
 O: objective findings of the mental health issue
 A: assessment of the mental health issue
 P: plan for the mental health issue
Medication Administration Record
 The MAR is the “Bible” for medication the patient is receiving. It
is what the nurse uses when administering medication and states
medication, dose, administration route, & time.
 The MAR includes both scheduled and as needed (PRN)
medications.
 As needed medications are given in response to specific
symptoms. The nurse is responsible for documenting when the
symptom occurs and how the patient responded to the PRN
medication.
Behavior Tracking Sheet for
Psychotropic Medication
 When psychotropic medications are ordered a behavior
tracking record should also be included in the MAR. This
behavior tracking sheet lists the specific behaviors that the
psychotropic medication should be addressing. For each shift
the nurse documents the occurrence and severity of each
behavior. This is important for the prescriber as it provides a
clear picture of whether or not, from the perspective of the
nurse, the medication is working. It also provides a time line
that is easy to see what time of day the patients behaviors
worsen.
CNA Behavior Flow Sheet
 The nursing assistants spend a great deal of time engaging in
1:1 and very personal activities with the patients. They often
are the primary witness to problematic behavior.
 CNAs often act as the ‘barometer’ of mental health issues in
the long term care facilities making it extremely important
to view their assessment of problem behaviors.
 This is an important source of information for the mental
health consultant.
Continuity of information
 Each one of these areas of documentation should relate to the
next.
 Information won’t be exactly the same in each documented
area, but they should be similar.
 Audits will check for continuity in physicians orders, nurses
notes, psychiatric documents, flow sheets and MAR.
Targeted Behavioral Monitoring
Antipsychotic
 Targeted behavior requirements:
1. Need to be documented daily.
2. Should not be caused by preventable means.
3. Cause the resident to be a danger to self and/or others
 Accepted behaviors for antipsychotic use:
 Spitting, Biting, Kicking, Scratching, Fighting, hallucinations, Extreme
fear, Delusions, Pinching, Slapping, Head banging, Self-inflicted injury,
Tripping others, Purposeful vomiting, Continuously crying, Continuously
yelling, Continuously screaming, Inappropriate sexual behavior;
Purposeful pushing, Purposeful throwing objects, Purposeful ramming
others.
 Behaviors-which by themselves DO NOT warrant antipsychotic use.
 Wandering, Insomnia, Restlessness, Impaired Memory, Poor self care,
Anxiety, Fidgeting, Nervousness, Uncooperativeness, Depression w/o
psychotic features, Agitated behaviors which do not dose a threat to self
or others. Occasional yelling, crying out, screaming, pacing.
Targeted Behavioral Monitoring for
Antidepressants
 Targeted behavior requirements if no dx of depression is in place:
1.
2.
3.
Need to be documented daily.
Should not be caused by preventable means.
Cause the resident to be a danger to self and/or others.
 Behaviors are warranted if antidepressant is used for behavior modification.
 Spitting, Biting, Kicking, Scratching, Fighting, hallucinations, Extreme fear,
Delusions, Pinching, Slapping, Head banging, Self-inflicted injury, Tripping
others, Purposeful vomiting, Continuously crying, Continuously yelling,
Continuously screaming, Inappropriate sexual behavior; Purposeful pushing,
Purposeful throwing objects, Purposeful ramming others.
 Behaviors-which by themselves DO NOT warrant antidepressant use.
 Wandering, Insomnia, Restlessness, Impaired Memory, Poor self care, Anxiety,
Fidgeting, Nervousness, Uncooperativeness, Depression w/o psychotic
features, Agitated behaviors which do not dose a threat to self or others.
Occasional yelling, crying out, screaming, pacing.
Targeted behavior requirements for
anxiolytics
 Targeted behavior requirements:
1.
2.
3.
Need to be documented daily.
Should not be caused by preventable means.
Cause the resident to be a danger to self and/or others.
 Accepted behaviors:
 Spitting, Biting, Kicking, Scratching, Fighting, hallucinations, Extreme fear,
Delusions, Pinching, Slapping, Head banging, Self-inflicted injury, Tripping
others, Purposeful vomiting, Continuously crying, Continuously yelling,
Continuously screaming, Inappropriate sexual behavior; Purposeful pushing,
Purposeful throwing objects, Purposeful ramming others.
 Behaviors-which by themselves DO NOT warrant anxiolytic use.
 Wandering, Insomnia, Restlessness, Impaired Memory, Poor self care, Anxiety,
Fidgeting, Nervousness, Uncooperativeness, Depression w/o psychotic features,
Agitated behaviors which do not dose a threat to self or others. Occasional
yelling, crying out, screaming, pacing.
Targeted Behavior Monitoring for
Sedative/ Hypnotic
 DOES NOT REQUIRE TARGETED BEHAVIOR
MONITORING WITH PROPER DX IN PLACE:
 Do not require monitoring if given for sleep disorder.
Descriptive words
 It is important to use descriptive words and to avoid general
words like agitation. Agitation by definition includes up to
50 different types of behaviors.
 Be specific in documentation :
Mr. Jones was agitated after lunch
Mr. Jones had to be redirected by staff four times after lunch due to repeated attempts to stand
up without assistance while seated in his wheelchair next to the north nursing station.
 There are lists of descriptive words like the following one
that can be used to assist you in documentation.
List of descriptive words
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Verbal Hostility:
Venomous
Abusive
Threatening
Derisive
Derogatory
Scornful
Argumentative
Critical
Nagging
Outspoken
Frank
Tactful
Soft-spoken
Complimentary
Flattering
Mood:
Euphoric
Elated
Frivolous
Buoyant
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Gay
Jovial
Light-hearted
Cheerful
Placid
Sober
Serious
Solemn
Grave
Gloomy
Brooding
Disconsolate
Hopeless
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Physical Hostility:
Murderous
Assaultive
Destructive
Combative
Hot blooded
Even tempered
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Peaceable
Harmless
Inhibited
Placated
Cringing
Anxiety:
Terrified
Panicky
Agitated
Tremulous
Apprehensive
Tense
Fretful
Uneasy
Composed
Calm
Non-chalant
Unconcerned
Cool
Bland
Stoic
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Impulsiveness:
Incontinent
Reckless
Rash
Impetuous
Excitable
Hasty
Abrupt
Restless
Spontaneous
Self-possessed
Cool-headed
Controlled
Restrained
Staid
Sluggish
Care Plan
 The care plan will be developed from the assessments and
diagnoses.
 Using descriptive words will improve the quality of
documentation.
 Descriptive words will make documenting more efficient by
improving the clarity of what we are assessing for and what
the goals are.
Thought Provoking Questions:
 Why is it important for continuity in
documentation?
 Where will the mental health consultant
seek out information about a patient?
 How can you improve your own
documentation?