Documenting “CTSS-wise”

First -Procentive New Features

• Sending Faxes from Procentive is now available

• Open the document in Procentive that you want to fax.

• Click “fax this” at the top of the screen

Faxing in Procentive

• Fill in the “to” name and fax number or select from contacts.

• Click save to send.

“Workflow” is now operational

• What this means is case notes that are not entered when time is entered will be flagged.

• “Workflow” will blink on the side toolbar in Procentive.

• Tom Belcher, our beloved Quality Assurance Coordinator, will be notified.

• The team will need to take it up.

• Don’t let this happen, make the case note when entering your time, enter your time promptly.

Opening an Insurance Case

You need to have:

• Application

• General Waiver

• Medical Waiver

• Authorization for Release of Information Forms

• Primary Care Physician Release

• Crisis Plan

• SDQ,CASII (Enter in CASPIO every six months.)

DA Session

• Should have 29 Points

• Includes SDQ and CASII (Use data collection tool)

• Must be completed and signed before counselor bills.

• Therapist can bill one session prior to D/A

Treatment Plan

• Check off and list outside service providers

Treatment Plan

• Presenting Problem, Cultural follow from the D/A

Objectives

• Follow from the diagnosis (should be able to tell the diagnosis just from reading the objective)

• Must be measurable and behavioral (avoid %)

• Example:

“Client will decrease incidents of yelling, hitting, or throwing things from 3 of 5 interactions to 1 of five interactions for 4 consecutive weeks as reported by client and parent.”

Objectives

• 2 Examples

Client will _______________________________ _______________________________________

Client will ________________________________ _______________________________________

Strategies

• Follow from the objective

• If strategies are general they must be described more specifically in the narrative of the case note.

• If strategies are specific, they do not need to be written out in the narrative.

Strategies • It is better to put each strategy in a separate field (box) of the treatment plan. But, can put them all in the same field.

• If several strategies are listed in the same field on the ITP, the individual strategies worked on must be specified in the narrative of each case note.

Treatment Plan Signatures

• Sign in order if it works

• If not on the same day, then at next visit.

• Treatment plan must be signed before billing.

• (Therapists can bill one session prior)

Case Notes

• First enter the session in the time module.

• Case note pops up, if not, click on the little red box. Make sure the service line is associated with a time entry.

Case Notes • Note should be attached to a service line

• Date and time should flow from time module

• Enter travel by exact minutes (if billed to another client, write “BOC” in the “Total Time” box)

Follow Through from last Session

• Should flow through from “Plan” in the previous note (if not go back and get it). State parent/clients/teach reports that the behavior happened ______ times.

Objectives and Strategies in Case Notes

• Pick objectives and strategies that you worked on (as many as appropriate).

• Write more details in the narrative field about the strategies, unless they were very specific. Not simply “worked on self-calming skills” but instead say, “worked on self-calming skills of taking deep breaths, using stress balls, etc.”

Observations • Client’s response to the session

• State specifically how the client responded to the session. Must be concrete, observable behavior, Not, “Client appeared depressed,” instead say “Client cried, displayed flat affect, refused to participate initially, in the last half of the session, the client engaged more, made consistent eye contact, smiled.”

• Progress on objectives also goes here

• “Client used respectful interactions five times this week (or 5/7 times).”

Specific Plan

• State the client’s homework. If providing family skills/therapy, give the family members homework also.

• Can be a strategy. Should be clear that it is related to their treatment.

• “Parents will implement active ignoring 4 times in the next week and report to counselor on the success of that intervention.” Or “Client will substitute self calming strategies for aggression toward sibling 4 times in the next week.”

Procentive Example

Case Notes

• Always sign and date your documents

• Sign with credentials (for auditor’s reference)

Questions, Comments?