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Documentation of Care, Treatment, and Services in Behavioral Health Care: Your Go-to Guide, 2018
- Cover/title page
- Copyright page
- Table of Contents
- Introduction
- Chapter 1: Overview of Behavioral Health Care Documentation [Go to Page]
- SECTION SETS: The Basics of Behavioral Health Care Documentation [Go to Page]
- CC: Documentation of Care, Treatment, or Services
- II: The Five W’s of Behavioral Health Care Documentation
- II: Types of Behavioral Health Care Documentation
- EE: A Complete Clinical/Case Record
- PP: Dated and Authorized Orders
- SECTION SETS: The Cyclical Process of Care, Treatment, or Services [Go to Page]
- CC: Care, Treatment, or Services as an Integrated System
- II: Elements of the Care, Treatment, or Services Cyclical Process
- PP: Duration and Methods of Data Collection
- II: Data Analysis of the Individual's Behavior
- CC: Ongoing Action Planning Based on Data
- II: Action Implementation Review and Process Restart
- PP: Separation of Continuous Process
- SECTION SETS: Core Steps of Care, Treatment, or Services [Go to Page]
- II: Step-by-Step Care, Treatment, or Services
- CC: The Same Steps Across Behavioral Health Care
- EE: Relationship of Core Steps to the Cyclical Process
- II: Purpose of Documentation in the Core Steps
- SECTION SETS: Support for the Care, Treatment, or Services System [Go to Page]
- PP: Joint Commission Standards and Behavioral Health Care Documentation
- II: Principles and Practices in Behavioral Health Care Documentation
- PP: Documentation of Support Processes
- SECTION SETS: Effective, Quality Documentation
[Go to Page]
- PP: Formats of Behavioral Health Care Documentation
- FF: Records and Documentation: Format/Availability
- PP: Standardization of Documentation
- TT: Electronic Health Record Decision Checklist
- PP: Policies for Security and Retention of Documentation
- EE: Integrity and Security of Documentation
- CC: Documentation Policies and Procedures
- TT: Policies and Procedures Evaluation Checklist
- II: Characteristics of Effective Documentation
- PP: Quality Documentation for Evaluation of Practices and Progress
- TT: Outcomes Measurement Tracer Questions
- Successful Strategies: Measurement-Based Behavioral Health Care
- Scenarios to Study: Moving from Paper to Electronic Documentation
- Chapter 2: Documentation of Screening and Assessment of Care, Treatment, or Services [Go to Page]
- SECTIONS SETS: Initial Screening and Assessment [Go to Page]
- CC: Pinpointing the Type and Level of Care
- II: Screening Versus Assessment
- TT: Screening and Assessment Tool Evaluation Checklist
- II: Initial Screening Data
- PP: Specific Behavioral/Emotional Screening Data
- EE: Effects of Trauma, Abuse, Neglect, or Exploitation
- PP: Screening for Risk of Harm and Abuse, Neglect, Trauma, or Exploitation
- TT: Risk-of-Harm Screening Form
- II: Characteristics of Effective Suicide Screening Tools
- TT: Suicide Risk Assessment Form
- TT:
Suicide Risk Assessment Tracer Questions
- PP: Environmental Risks for Suicide
- EE: The Information to Be Collected
- II: Initial Screenings Data
- PP: Screening and Assessment at Intense Levels of Care, Treatment, or Services
- CC: Influence of Requirements on Screening and Assessment Documentation
- SECTION SETS: Physical Screening and Assessment [Go to Page]
- CC: Physical Assessment
- II: Requirements for Physical Assessment
- II: Physical Health Screenings
- FF: H&P Content for Behavioral Health Care
- PP: H&P Admissions Data for Outcomes Measurement in Eating Disorders Programs
- PP: Physical Screening and Assessment for Outdoor/Wilderness Programs
- TT: Physical Health Screening and Examination Forms
- PP: Coordinating Nonphysician and Physician Reports
- CC: Consequences of Physical Pain
- PP: Screening for Physical Pain
- TT: Physical Pain Assessment Questionnaire
- SECTION SETS: Behavioral/Emotional Screening and Assessment [Go to Page]
- CC: Continuation of Initial Behavioral/Emotional Assessment
- II: Follow-Up Behavioral/Emotional Assessments
- TT: Behavior Screening Checklist for ID/DD Programs
- TT: Behavioral/Emotional Assessment Form
- SECTION SETS: Other Assessment Data [Go to Page]
- CC: Complicated Cases
- II: Potentially Relevant Assessment Elements
- II: Strength Assessment
- TT: Strength Assessment Questionnaire
- PP: Strengths as Recovery Capital
- II: Cultural Assessment
- EE: Cultural Contributions to Conditions and Progress
- II: Considering Age/Generation
- PP: Spiritual Assessment
- TT: Spiritual Assessment Questionnaire
- EE: Spiritual Assessments from a Completed Questionnaire
- SECTION SETS: Analysis of Assessment Data [Go to Page]
- EE: Accurately Identifying Needs
- CC: Consolidation of Information for Evaluation
- II: Elements of a Diagnostic Summary
- PP: The Need for a Statement of Needs
- II: Prioritizing Needs for a Statement of Needs
- TT: Diagnostic Summary Form and Statement of Needs Form
- SECTION SETS: Screening and Assessment Challenges [Go to Page]
- PP: Common Problems in Behavioral Health Care Screening and Assessment Documentation
- CC: Variability of Outcomes from Similar Data
- II: Assessment Versus Summation
- PP: Documenting Verbal Assessment Discussions
- PP: Clear, Precise, and Accurate Language
- EE: Analysis Written in Clear Language
- PP: Difficulty of Assessment Posed by Substance Abuse
- Successful Strategies: Screening and Assessment for Trauma/Abuse in Substance Use Programs
- Scenarios to Study: Revising Documentation for Requirements and Improvement
- Chapter 3: Documentation of Planning, Delivery, and Continuity of Care, Treatment, or Services [Go to Page]
- SECTION SETS: Planning of Care, Treatment, or Services [Go to Page]
- CC: A Well-Developed Plan
- II: Documenting Goals and Objectives
- II: Defining Dates for Goals
- CC: Specific, Measurable Objectives
- PP: Documenting Planned Interventions
- PP: Using Practice Guidelines to Develop the Plan
- II: The Individual’s Participation in Planning
- EE: Documentation of the Individual’s Participation
- TT: Coping Strategies Preferences Form
- II: Clinical/Case Record Versus Plan for Care, Treatment, or Services
- TT: Plan for Care, Treatment, or Services
- SECTION SETS: Delivery of Care, Treatement, or Services [Go to Page]
- CC: A Sequence of "Mini-Plans"
- II: Documenting Responses to Interventions
- PP: Documentation for Coordination of Care, Treatment, or Services
- CC: Sequential Narratives on Progress
- II: Progress Notes Versus Process Notes
- PP: Collaborative Progress Notes
- TT: Progress Note Form
- II: Progress Notes as Cues for Plan Revision
- SECTION SETS: Continuity of Care, Treatment, or Services [Go to Page]
- CC: Continuity at Transfer or Discharge
- II: Documenting Discharge Activities
- PP: Discharge Planning
- II: Documentation of Needs for a Continuing Plan for Care, Treatment, or Services
- TT: Discharge Summary Form
- TT: Recovery Safety Plan
- EE: Young Adults and Continuity of Care, Treatment, or Services
- PP: When Discharge Isn’t Part of the Plan
- SECTION SETS: Planning, Delivery, and Continuity Challenges
[Go to Page]
- CC: Proper Documentation
- PP: Reviewing and Updating the Plan
- TT: Plan Review Form
- II: Characteristics of Effective Plans for Care, Treatment, or Services
- TT: Plan for Care, Treatment, or Services Evaluation Checklist
- PP: Documenting Medications
- TT: Medication Reconciliation Form
- EE: Documenting Special Behavioral Procedures
- PP: Special Programs Documentation
- TT: Restraint and Seclusion Tracer Questions
- PP: Cultural Barriers to Successful Discharge
- PP: Education of Individuals on Care, Treatment, or Services
- TT: Required BHC Individual-Served Education and Information Checklists
- TT: BHC Documentation Performance Evaluation Checklist
- Successful Strategies: Documentation of Planning, Delivery, and Continuity in Behavioral Health Home
- Scenarios to Study: Involving the Individual in Creating the Plan for Care, Treatment, or Services
- Appendix: Tools to Try
- Glossary
- Index
- Back cover [Go to Page]