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Clinical Documentation IOP

Topic #3:

Clinical Documentation

What are your various documentation responsibilities at your site? What are some of the easiest aspects of documentation? What are some of the difficult aspects of documentation? Include a de-

identified example of your documentation in this week’s paper (e.g., progress note, treatment plan).

Brian, at the IOP Paxcampus, my only documentation is Client notes after shadowing Therapist in groups, and I now am the trainee therapist on MONDAY’s only for women gender group where anything is discussed amongst women. Like PMS’ing while recovering, Relapse in/women when you are PMS’ing, codependency, depression, anxiety, fear.

Include a de-identified example of your documentation in this week’s paper (e.g., progress note, treatment plan).

Clinical Documentation IOP

Introduction

Clinical documentation is the process by which a patient’s medical or therapy process is noted down in terms of the diagnosis as well as the medication and healing process. At the PAX Center, Intensive Out Patient, I have realized that clinical documentation has the following responsibilities based on my interactions:

First is that it enables the center to prepare in advance, whenever a patient is to be registered for an Outpatient program, I have realized that there is the need for the facility to understand whether they can handle the case successfully or efficiently. This, therefore, means that the referral source must send me the information and hence I review and give a feedback within a period of seven days. The document I use here is referred to as Prior Authorization. Hence this type of documentation enables the center to prepare in advance the desired treatment plan.

Secondly is that the facility must understand how the progress pf he patient is in terms of response to medication and or therapy. To understand this better, I must look at the Continued Stay Review which is filled after every seven days which makes it very easy to analyze the healing process. This will enable me to understand if it is best to discharge the patient or not.

Third responsibility is that clinical documentation enables me to understand the correct time a patient is to be or is discharged. Here a Discharge Review is required to be filed which will tell when the patient was discharged and the state of his or her health. This is important for both the patient and the facility itself especially for future reference as well as legal requirements in case of a problem.

Therefore, in general, I find that proper clinical documentation helps to link the diagnosis of a patient, the current presentation, and the strategies for treatment, the progress of treatments, how the services are beneficial, the criteria for discharge and the plan.

Also, they help in writing review request that will help a reader get a current clinical state of the specific member and any other goals as well as progress of the requested review which supports the continuity of the service.

Another responsibility is that proper clinical documentation helps in identification of the correct billing status and avoid confusion that may lead to conflicts between the facility and the patient.

Some of the easiest aspects of documentation

Clinical documentation is not as complex anymore since it has been infused with a lot of technical aspects that makes it super manageable. I found that at The PAX Center, there is the use of SNOMED-CT which has greatly reduced variations in the way data is captured, changed to codes and then stored for future use. This makes it easy to group related data together for research and analysis.es

The second aspect is that of high performance or low latency process of the clinical narrative. Since the PAX Center is a very busy facility, it becomes very easy for the clinicians to capture large data very fast and devote their time to other functions of the facility.

Supporting the terminology query framework, here it is very easy to do queries on the system in search of information. This helps save time and is very efficient.

Also, it is easy to map out clinical expressions to other coding systems making the use of clinical data across many systems is very easy and this makes data management an easy task.

The last easy aspect of clinical documentation is that I find the human understanding aspect very efficient. Thus, all the qualified clinical documentation staffs will be able to understand any data in whichever format it may be presented through.

Some of the difficult aspects of documentation

Lack of documentation, here I find it very difficult to keep a medical record that is not available. This means that the practitioners may have not recovered the various items that pertain a patient and this leaves a very big gap between the patent and the clinical documentation staff who may not be able to work out the issue as required. For example, lack of treatment plan may mean that a patient’s treatment procedure and the medication he or she received may not be able to be captured.

The second problem that I found to be very common is the electronic medical records that do not have narratives. Here every medical record must state what it is, who collected and recorded the data when was the data taken, is it data for a new client or a repeated client. As such one may be able to distinguish and tell the medical history of a patient. But for the case when such narratives are not there, this means that this data may be confusing and can lead to fatal medical interpretation situations.

The third challenge is that some of the clinicians even after doing their work very well and the client is getting better, they may answer or document he OASIS questions very wrongly and this may result in poor or bad payments due to the errors. Therefore, it would be best if the clinicians are trained to properly document the OASIS questions.

The progress notes for client two suffering form depression, anxiety, codependency Include a de-identified example of your documentation in this week’s paper (e.g., progress note, treatment plan). This is just an example. Please create

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Columbia Hospital Progress Note

Date of service: 25/9/2018

Billing Formula: Minutes of Service 30 + Documentation Time: 6 +Travel time: __ -Total Billable Minutes: 25

Service Provided: Collateral

Location of Service: Phone

Treatment Plan objective client is working on:

The diagnosis of the client with depressed mood as demonstrated by poor functioning in academics, too much tear and having fears of separation. These conditions are causing him emotional pain and thus cannot have meaningful relationships with his caregivers. The client will have to therefore increase the use if only positive statements from twice a week to four times a week for four months. Currently the client has started seeing positivity in many things.

Narrative:

Clients Current Functioning/Progress: according to the report of his foster uncle, the client does not like hanging around peers. He also does not want to create interpersonal relationships with family members. This was a phone call from the client’s concerned foster uncle.

Current intervention: I enquired for the foster uncle whether the clients had shown any intentions to harm others. He said that the client had not opened about his depression and that he needs advice on how he can handle the client. I thus discussed with the foster uncle the relevant techniques as we had discussed in session that the client agreed to that included offer space in his room as well as occasionally invite the client for conversation. The foster uncle promised to use the techniques though she mostly forgets and thinks that he does not understand what he can do.

Client's response: N/A the foster uncle appreciated the phone conversation and will stick to the discusses techniques

Follow-up and/or Referrals Made: will arrange for a family meeting on 9-28-2018

Teresa 25/9/2018

Signature and Job title Date completed

Therapist three

Client Name: Client two AVATAR Number: 456 789