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Your Go-To Guide

Documentation IN BEHAVIORAL HEALTH CARE

of Care, Treatment, or Services

Joint Commission Resources Mission The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services.

Disclaimers JCR educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of JCR publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a JCR publication should not be construed as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval.

This publication is designed to provide accurate and authoritative information regarding the subject matter covered. Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject to change. Please also note that some of the examples in this publication are specific to the laws and regulations of the locality of the facility. The information and examples in this publication are provided with the understanding that the publisher is not engaged in providing medical, legal, or other professional advice. If any such assistance is desired, the services of a competent professional person should be sought.

Joint Commission Resources Oak Brook, Illinois 60523 http://www.jcrinc.com

Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission.

All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Requests for permission to make copies of any part of this work should be sent to [email protected].

ISBN (print): 978-1-63585-043-7 ISBN (e-book): 978-1-63585-044-4

Printed in the USA

For more information about The Joint Commission, please visit http://www.jointcommission.org.

Acknowledgments Content Development Manager: Lisa K. Abel Senior Editor: Phyllis Crittenden Project Manager: Lisa M. King Associate Director, Publications: Helen M. Fry, MA Associate Director, Production and Meeting Support: Johanna Harris Executive Director, Global Publishing: Catherine Chopp Hinckley, MA, PhD

Reviewers Joint Commission Division of Healthcare Improvement Julia Finken, BSN, MBA, Executive Director, Behavioral Health Care Accreditation Program; Peggy Lavin, LCSW, Senior Associate Director, Business Development, Behavioral Health Care Accreditation Program; Kathryn Petrovic, MSN, RN-BC, Senior Associate Director, Standards Interpretation Group; Peter Vance, LPCC, CPHQ, Field Director, Department of Accreditation and Certification Operations; Merlin Wessels, LCSW, Associate Director, Standards Interpretation Group

Joint Commission Division of Healthcare Quality Evaluation Lynn Zielinski, MLA, Project Director, Department of Standards and Survey Methods

mailto:permissions%40jcrinc.com?subject=

http://www.jointcommission.org

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Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

CHAPTER 1

Overview of Behavioral Health Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SECTION SETS The Basics of Behavioral Health Care Documentation CONCISE CONCEPTS Documentation of Care, Treatment, or Services . . . . . . . . . . . . . . . . . . 2 INSTRUCTIVE INFOGRAPHICS The Five W ’s of Behavioral Health Care Documentation . . . . . . . . . . 3 INSTRUCTIVE INFOGRAPHICS Types of Behavioral Health Care Documentation . . . . . . . . . . . . . . . . 4 EXCERPTS THAT EXPLAIN A Complete Clinical/Case Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 PARTICULAR POINTS Dated and Authorized Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

SECTION SETS The Cyclical Process of Care, Treatment, or Services CONCISE CONCEPTS Care, Treatment, or Services as an Integrated System . . . . . . . . . . . . 7 INSTRUCTIVE INFOGRAPHICS Elements of the Care, Treatment, or Services Cyclical Process . . . . . 8 PARTICULAR POINTS Duration and Methods of Data Collection . . . . . . . . . . . . . . . . . . . . . . . 8 INSTRUCTIVE INFOGRAPHICS Data Analysis of the Individual’s Behavior . . . . . . . . . . . . . . . . . . . . . . . 9 CONCISE CONCEPTS Ongoing Action Planning Based on Data . . . . . . . . . . . . . . . . . . . . . . 10 INSTRUCTIVE INFOGRAPHICS Action Implementation Review and Process Restart . . . . . . . . . . . . 10 PARTICULAR POINTS Separation of a Continuous Process . . . . . . . . . . . . . . . . . . . . . . . . . . 11

SECTION SETS Core Steps of Care, Treatment, or Services INSTRUCTIVE INFOGRAPHICS Step-by-Step Care, Treatment, or Services . . . . . . . . . . . . . . . . . . . . . 13 CONCISE CONCEPTS The Same Steps Across Behavioral Health Care . . . . . . . . . . . . . . . . 14 EXCERPTS THAT EXPLAIN Relationship of Core Steps to the Cyclical Process . . . . . . . . . . . . . . 14 INSTRUCTIVE INFOGRAPHICS Purpose of Documentation in the Core Steps . . . . . . . . . . . . . . . . . . 15

SECTION SETS Support for the Care, Treatment, or Services System PARTICULAR POINTS Joint Commission Standards and Behavioral Health Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 INSTRUCTIVE INFOGRAPHICS Principles and Practices in Behavioral Health Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 PARTICULAR POINTS Documentation of Support Processes . . . . . . . . . . . . . . . . . . . . . . . . . 18

SECTION SETS Effective, Quality Documentation PARTICULAR POINTS Formats of Behavioral Health Care Documentation . . . . . . . . . . . . . 19 FOCUS ON FAQS Records and Documentation: Format/Availability . . . . . . . . . . . . . . . 20 PARTICULAR POINTS Standardization of Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 TOOLS TO TRY Electronic Health Record Decision Checklist . . . . . . . . . . . . . . . . . . . 21 PARTICULAR POINTS Policies for Security and Retention of Documentation . . . . . . . . . . . 21 EXCERPTS THAT EXPLAIN Integrity and Security of Documentation . . . . . . . . . . . . . . . . . . . . . . . 22 CONCISE CONCEPTS Documentation Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . 22 TOOLS TO TRY Policies and Procedures Evaluation Checklist . . . . . . . . . . . . . . . . . . 22

Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

INSTRUCTIVE INFOGRAPHICS Characteristics of Effective Documentation . . . . . . . . . . . . . . . . . . . . 23 PARTICULAR POINTS Quality Documentation for Evaluation of Practices and Progress . . 24 TOOLS TO TRY Outcomes Measurement Tracer Questions . . . . . . . . . . . . . . . . . . . . . 24

SUCCESSFUL STRATEGIES Measurement-Based Behavioral Health Care . . . . . . . 25

SCENARIOS TO STUDY Moving from Paper to Electronic Documentation . . . . . . . 28

CHAPTER 2

Documentation of Screening and Assessment of Care, Treatment, or Services . . 33

SECTION SETS Initial Screening and Assessment CONCISE CONCEPTS Pinpointing the Type and Level of Care . . . . . . . . . . . . . . . . . . . . . . . . 35 INSTRUCTIVE INFOGRAPHICS Screening Versus Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 TOOLS TO TRY Screening and Assessment Tool Evaluation Checklist . . . . . . . . . . . 36 INSTRUCTIVE INFOGRAPHICS Initial Screening Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 PARTICULAR POINTS Specific Behavioral/Emotional Screening Data. . . . . . . . . . . . . . . . . . 37 EXCERPTS THAT EXPLAIN Effects of Trauma, Abuse, Neglect, or Exploitation . . . . . . . . . . . . . . 37 PARTICULAR POINTS Screening for Risk of Harm and Abuse, Neglect, Trauma, or Exploitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 TOOLS TO TRY Risk-of-Harm Screening Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 INSTRUCTIVE INFOGRAPHICS Characteristics of Effective Suicide Screening Tools . . . . . . . . . . . . . 39 TOOLS TO TRY Suicide Risk Assessment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 TOOLS TO TRY Suicide Risk Assessment Tracer Questions . . . . . . . . . . . . . . . . . . . . 40 PARTICULAR POINTS Environmental Risks for Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 EXCERPTS THAT EXPLAIN The Information to Be Collected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 INSTRUCTIVE INFOGRAPHICS Initial Screenings Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 PARTICULAR POINTS Screening and Assessment at Intense Levels of Care, Treatment, or Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 CONCISE CONCEPTS Influence of Requirements on Screening and Assessment Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

SECTION SETS Physical Screening and Assessment CONCISE CONCEPTS Physical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 INSTRUCTIVE INFOGRAPHICS Requirements for Physical Assessment . . . . . . . . . . . . . . . . . . . . . . . . 44 INSTRUCTIVE INFOGRAPHICS Physical Health Screenings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 FOCUS ON FAQS H&P Content for Behavioral Health Care . . . . . . . . . . . . . . . . . . . . . . . 48 PARTICULAR POINTS H&P Admissions Data for Outcomes Measurement in Eating Disorders Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 PARTICULAR POINTS Physical Screening and Assessment for Outdoor/Wilderness Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 TOOLS TO TRY Physical Health Screening and Examination Forms . . . . . . . . . . . . . . 49 PARTICULAR POINTS Coordinating Nonphysician and Physician Reports . . . . . . . . . . . . . . 49 CONCISE CONCEPTS Consequences of Physical Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 PARTICULAR POINTS Screening for Physical Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 TOOLS TO TRY Physical Pain Assessment Questionnaire . . . . . . . . . . . . . . . . . . . . . . 50

SECTION SETS Behavioral/Emotional Screening and Assessment CONCISE CONCEPTS Continuation of Initial Behavioral/Emotional Assessment . . . . . . . . . 51 INSTRUCTIVE INFOGRAPHICS Follow-Up Behavioral/Emotional Assessments . . . . . . . . . . . . . . . . . 52 TOOLS TO TRY Behavior Screening Checklist for ID/DD Programs . . . . . . . . . . . . . . 53 TOOLS TO TRY Behavioral/Emotional Assessment Form . . . . . . . . . . . . . . . . . . . . . . . 53

SECTION SETS Other Assessment Data CONCISE CONCEPTS Complicated Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 INSTRUCTIVE INFOGRAPHICS Potentially Relevant Assessment Elements . . . . . . . . . . . . . . . . . . . . . 55 INSTRUCTIVE INFOGRAPHICS Strength Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 TOOLS TO TRY Strength Assessment Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . 56 PARTICULAR POINTS Strengths as Recovery Capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 INSTRUCTIVE INFOGRAPHICS Cultural Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 EXAMPLES TO EXAMINE Cultural Contributions to Conditions and Progress . . . . . . . . . . . . . . 59 INSTRUCTIVE INFOGRAPHICS Considering Age/Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 PARTICULAR POINTS Spiritual Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 TOOLS TO TRY Spiritual Assessment Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 EXAMPLES TO EXAMINE Spiritual Assessments from a Completed Questionnaire . . . . . . . . . 61

SECTION SETS Analysis of Assessment Data EXCERPTS THAT EXPLAIN Accurately Identifying Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 CONCISE CONCEPTS Consolidation of Information for Evaluation . . . . . . . . . . . . . . . . . . . . 63 INSTRUCTIVE INFOGRAPHICS Elements of a Diagnostic Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 PARTICULAR POINTS The Need for a Statement of Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 INSTRUCTIVE INFOGRAPHICS Prioritizing Needs for a Statement of Needs . . . . . . . . . . . . . . . . . . . . 64 TOOLS TO TRY Diagnostic Summary Form and Statement of Needs Form . . . . . . . 65

SECTION SETS Screening and Assessment Challenges PARTICULAR POINTS Common Problems in Behavioral Health Care Screening and Assessment Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 CONCISE CONCEPTS Variability of Outcomes from Similar Data . . . . . . . . . . . . . . . . . . . . . . 66 INSTRUCTIVE INFOGRAPHICS Assessment Versus Summation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 PARTICULAR POINTS Documenting Verbal Assessment Discussions . . . . . . . . . . . . . . . . . . 68 PARTICULAR POINTS Clear, Precise, and Accurate Language . . . . . . . . . . . . . . . . . . . . . . . . 68 EXAMPLES TO EXAMINE Analysis Written in Clear Language . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 PARTICULAR POINTS Difficulty of Assessment Posed by Substance Abuse . . . . . . . . . . . . 70

SUCCESSFUL STRATEGIES Screening and Assessment for Trauma/Abuse in Substance Use Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

SCENARIOS TO STUDY Revising Documentation for Requirements and Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

CHAPTER 3

Documentation of Planning, Delivery, and Continuity of Care, Treatment, or Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

SECTION SETS Planning of Care, Treatment, or Services CONCISE CONCEPTS A Well-Developed Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 INSTRUCTIVE INFOGRAPHICS Documenting Goals and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 INSTRUCTIVE INFOGRAPHICS Defining Dates for Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 CONCISE CONCEPTS Specific, Measurable Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 PARTICULAR POINTS Documenting Planned Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . 81 PARTICULAR POINTS Using Practice Guidelines to Develop the Plan . . . . . . . . . . . . . . . . . 82 INSTRUCTIVE INFOGRAPHICS The Individual’s Participation in Planning . . . . . . . . . . . . . . . . . . . . . . . 82 EXAMPLES TO EXAMINE Documentation of the Individual’s Participation . . . . . . . . . . . . . . . . . 83 TOOLS TO TRY Coping Strategies Preferences Form . . . . . . . . . . . . . . . . . . . . . . . . . . 84 INSTRUCTIVE INFOGRAPHICS Clinical/Case Record Versus Plan for Care, Treatment, or Services . . 84 TOOLS TO TRY Plan for Care, Treatment, or Services . . . . . . . . . . . . . . . . . . . . . . . . . 85

SECTION SETS Delivery of Care, Treatment, or Services CONCISE CONCEPTS A Sequence of “Mini-Plans” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 INSTRUCTIVE INFOGRAPHICS Documenting Responses to Interventions . . . . . . . . . . . . . . . . . . . . . . 87 PARTICULAR POINTS Documentation for Coordination of Care, Treatment, or Services . . 87 CONCISE CONCEPTS Sequential Narratives on Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 INSTRUCTIVE INFOGRAPHICS Progress Notes Versus Process Notes. . . . . . . . . . . . . . . . . . . . . . . . . 88 PARTICULAR POINTS Collaborative Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 TOOLS TO TRY Progress Note Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 INSTRUCTIVE INFOGRAPHICS Progress Notes as Cues for Plan Revision . . . . . . . . . . . . . . . . . . . . . . 90

SECTION SETS Continuity of Care, Treatment, or Services CONCISE CONCEPTS Continuity at Transfer or Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 INSTRUCTIVE INFOGRAPHICS Documenting Discharge Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 PARTICULAR POINTS Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 INSTRUCTIVE INFOGRAPHICS Documentation of Needs for a Continuing Plan for Care, Treatment, or Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 TOOLS TO TRY Discharge Summary Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 TOOLS TO TRY Recovery Safety Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 EXCERPTS THAT EXPLAIN Young Adults and Continuity of Care, Treatment, or Services . . . . . 95 PARTICULAR POINTS When Discharge Isn’t Part of the Plan . . . . . . . . . . . . . . . . . . . . . . . . . 95

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SECTION SETS Planning, Delivery, and Continuity Challenges CONCISE CONCEPTS Proper Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 PARTICULAR POINTS Reviewing and Updating the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 TOOLS TO TRY Plan Review Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 INSTRUCTIVE INFOGRAPHICS Characteristics of Effective Plans for Care, Treatment, or Services . . 98 TOOLS TO TRY Plan for Care, Treatment, or Services Evaluation Checklist . . . . . . . 99 PARTICULAR POINTS Documenting Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 TOOLS TO TRY Medication Reconciliation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 EXCERPTS THAT EXPLAIN Documenting Special Behavioral Procedures . . . . . . . . . . . . . . . . . 100 PARTICULAR POINTS Special Programs Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 TOOLS TO TRY Restraint and Seclusion Tracer Questions . . . . . . . . . . . . . . . . . . . . . 101 PARTICULAR POINTS Cultural Barriers to Successful Discharge . . . . . . . . . . . . . . . . . . . . . 101 PARTICULAR POINTS Education of Individuals on Care, Treatment, or Services . . . . . . . . 102 TOOLS TO TRY Required BHC Individual-Served Education and Information Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 TOOLS TO TRY BHC Documentation Performance Evaluation Checklist. . . . . . . . . 102

SUCCESSFUL STRATEGIES Documentation of Planning, Delivery, and Continuity in Behavioral Health Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

SCENARIOS TO STUDY Involving the Individual in Creating the Plan for Care, Treatment, or Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Appendix: Tools to Try . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

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Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

Introduction

Documentation. Documentation. Documentation. As in so many other areas of health care, documentation affects nearly every aspect of care,

treatment, or services in behavioral health care. The list of documentation types and uses in this area is long and includes the following:

■■ Screenings and assessments to support the development of a plan of care, treatment, or services and to guide ongoing interactions with the individuals served

■■ Plans to guide care, treatment, or services and progress notes to provide a means of communication among clinicians, staff, and individuals served (and their families/ guardians and significant others, as appropriate)

■■ Assessments, plans, and progress notes to justify interventions to third-party payers

■■ Performance measurement data to help organizations identify potential or actual problems in their processes and to improve the quality of care, treatment, or services

■■ Specific content required to meet regulatory and accreditation requirements

These aren’t new uses for documentation, but they indicate that the need for accurate, timely, and appropriate documentation is as great as it has ever been. Note, however, that The Joint Commission has strategically tried to reduce its focus on documentation during the survey process and instead talks with and listens to organization representatives during the survey and observes how care, treatment, and services are delivered.

Changes to Behavioral Health Care Documentation Standards Although uses for behavioral health care documentation may not be new, many Joint Commission behavioral health care standards are new or have changed quite a bit in recent years. You should, of course, check the most current version of the standards in your Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) or its online E-dition® version. Documentation require ments are indicated by a documentation icon next to the requirement. Some of the recent changes to requirements relevant to clinical/case documentation are summarized as follows:

Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

■■ Organization providing Prevention and Wellness Promotion Services are required to do the following:

■✖ Have a written plan for providing those prevention and wellness promotion services relevant to the organization’s mission and scope of services.

■■ Behavioral Health Home (BHH) programs (an optional certification) are required to do the following:

■✖ Be accredited under the behavioral health care accreditation standards. ■✖ Meet additional standards regarding integration of behavioral and physical health care, treatment, or services, as described in the BHH chapter of the CAMBHC.

■■ Opioid Treatment programs, as defined in the CAMBHC, are required to do the following:

■✖ Document reasons for denying any pregnant applicant. ■✖ Receive written authorization to provide interim maintenance treatment from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the state’s chief public health officer (if the organization provides such treatment).

■✖ Have written criteria for prioritizing the transfer of individuals served from interim maintenance treatment to comprehensive maintenance treatment.

■✖ Display names and telephone numbers of whom to contact in case of emergency.

■■ Organizations providing Housing Support Services, as defined in the CAMBHC, are required to do the following:

■✖ Document their regular face-to-face meetings between the individual served and staff.

■✖ Perform and document good faith efforts to rapidly rehouse individuals served who have lost their housing due to eviction.

■✖ Document the status of individuals reviewed at each meeting of the multidisciplinary care, treatment, or services team (if the organization directly provides both housing support and behavioral or physical health care, treatment, or services).

■■ Organizations providing care, treatment, or services to individuals with eating disorders are required to do the following:

■✖ Perform or make a documented referral for a series of specific physical tests, screenings, and procedures.

■✖ Assess outcomes of care, treatment, or services based on data collected at admission.

■■ Assessing outcomes in any behavioral health setting accredited under the CAMBHC requires the following:

■✖ Use of a standardized tool or instrument to monitor the individual’s progress in achieving that person’s goals.

■✖ Gathering, analyzing, and using data generated through standardized monitoring.

This book reflects the most recent set of behavioral health care accreditation and behavioral health care home certification standards available at the time of its writing, as found in the 2018 online E-dition and print version of the CAMBHC.

Introduction

Documentation Themes in This Book The content of this book not only reflects recent changes to behavioral health care clinical/case documentation standards but also addresses several important emerging and evergreen themes regarding behavioral health care clinical/case documentation. These include the following:

■■ Measuring outcomes: Documentation should support the measurement of an individual’s outcomes as that person responds to care, treatment, or services—outcomes that are applicable to multiple purposes, including adapting the plan for care, treatment, or services as necessary.

■■ Adjusting plans to support the individual’s progress: Documentation should inform and support changes to the individual’s plan for care, treatment, or services as the individual progresses (or regresses).

■■ Integration of physical and behavioral health care: Documentation should integrate both physical and behavioral/emotional assessment of the individual served, to identify and address areas where those aspects of health affect each other.

■■ Care, treatment, or services centered around the individual served: Documentation should incorporate the individual’s own words as much as possible to encourage that person’s investment in progress toward recovery or as part of continuing care, treatment, or services.

■■ Quality, effective documentation: Documentation should be easy to read and understand, thorough, accurate, and timely.

■■ Recovery/resilience, with a focus on the individual’s needs, strengths, preferences, and goals: Documentation should support the recovery or resilience of individuals served, always centered around how the individual’s needs, strengths, and preferences can be used to meet the individual’s goals.

Audience for This Book This book is written for anyone in a behavioral health care organization who works with documentation of the care, treatment, or services provided to individuals served. The focus is on helping accredited organizations maintain compliance and create and use effective documentation. However, non-accredited organizations may also benefit from this book, as they can use it to learn about the Joint Commission’s expectations regarding documentation.

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Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

■ Chapter 1 Overview of Behavioral Health Care Documentation: This chapter introduces the basic concepts of documentation in behavioral health care. It explains the importance of documentation and describes the various types of documentation that occur during care, treatment, or services. Discussions of the cyclical process of care, treatment, or services and the core steps of that cyclical process are central topics in the chapter. The chapter also includes information about other organizational systems supported by documentation activities, and it concludes with a discussion of the factors that affect the development of effective, high-quality documentation.

■ Chapter 2 Documentation of Screening and Assessment of Care, Treatment, or Services: This chapter discusses several important types of screenings and assess- ments used in behavioral health care, including the initial, physical, and behavioral/ emotional screenings and assessments. Information on other assessment data—such as strength, cultural, generational, and spiritual assessments—is also provided. The chapter concludes with discussions of analyzing data collected from screenings and assessments and common challenges you may encounter when performing these activities.

■ Chapter 3 Documentation of Planning, Delivery, and Continuity of Care, Treatment, or Services: This chapter focuses on how information gathered through screenings and assessments is used in the planning, delivery, and continuity of care, treatment, or services. It emphasizes the participation of the individual served throughout the process: from creating the individualized plan for care, treatment, or services, to responding to changes, to transitioning to another level of care, treatment, or services through transfer or discharge. The chapter describes some related challenges and how to address them effectively.

An appendix and a glossary of terms are included in this book as well. Each contains important materials you need to get the most out of this book. They are as follows:

■ Appendix: Tools to Try: The Appendix provides a number of documentation forms, checklists, and other tools. One set of tools has been standardized in form and content to demonstrate how documentation tools work together; these tools are designed to be easy to use, yet comprehensive in application to the process of care, treatment, or services. Several of these documentation forms are shown completed for a fictional individual served. All are included in blank form for download: Users of the e-book download from links, while users of the print edition go to a website address* provided to download the tools. Content in these forms represent appropriate content for hard- copy (paper) forms or electronic health record (EHR) forms of the type represented. Note that The Joint Commission does not endorse or require any of these specific, particular example forms.

■ Glossary: The Glossary defines all the key terms listed in each chapter. If you’re using the electronic version of this book, each term is hyperlinked at the opening of each chapter and at an important use in the chapter; clicking on the hyperlinked terms in the text will take you to the Glossary.

Structure of This Book Documentation of Care, Treatment, or Services in Behavioral Health Care: Your Go-To Guide is a clear, concise, accurate reference that breaks down complex concepts into easy-to-digest pieces. You can read them in order, or you can jump to the topic you need. The book includes three chapters:

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Introduction

Terms &topics

SECTION SETS

A New Approach: Information for Application Understanding and applying the standards regarding clinical/case documentation in behavioral health care settings can be challenging. After all, these standards deal with the myriad issues of providing quality care, treatment, or services of individuals served in numerous and various settings, programs, and services. To help you understand the documentation requirements in behavioral health care, Joint Commission Resources has published four editions of a particular book on this topic: A Practical Guide to Documentation in Behavioral Health Care. The most recent edition was published in 2012.

Since 2012, behavioral health care standards have changed significantly—and so has the way information is shared. We now get much of our published information in accessible and succinct chunks—often framed in a mobile device and/or online in brief text blocks, bulleted lists, and informational graphics (infographics). Also, the information itself is more practical than theoretical; it’s often intended to be immediately applicable: Read it and use it. This reflects an understanding that consumers don’t have much time to spare to get the information and tools they need right now.

In response to this development in learning and publishing, Joint Commission Resources has created a new approach for some of its books—one that makes even complex content easier to read and use. Documentation of Care, Treatment, or Services in Behavioral Health Care: Your Go-To Guide uses this new approach to offer new information as well as updated content from the most recent edition of A Practical Guide to Documentation in Behavioral Health Care.

The content is presented in a way that takes you swiftly from information to application. Each chapter starts with a brief introduction and then presents information through a series of short, recurring features. These features are written to stand alone, although they do follow a logical order within the chapter.

To help you quickly find what you’re looking for, the features are grouped into sections related to a set of specific standards. The standards are mostly from the “Care, Treatment, and Services” and “Record of Care, Treatment, and Services” chapters of the online E-dition and print version of the CAMBHC, though relevant standards from other chapters are included as well. Each chapter contains several sections that include one or more of each of the features described below.

■ Terms & Topics: This feature appears right after the introduction to each chapter. It contains a list of important terms (defined in the Glossary) that you’ll encounter in the chapter. It also lists the topics covered in the chapter sections and the relevant standards for each. Each topic has its own section in the chapter, introduced by a “Section Sets” feature (described next). Terms and relevant standards are indicated in underlined blue text so you know to look for them in the Glossary. As already noted, for those using the electronic version of this book, these terms are hyperlinked to the Glossary.

■ Section Sets: This feature is used to open a section on one of the topics listed in the Terms & Topics feature. It provides a brief description of the main issues covered in the relevant standards for the topic and includes the text of relevant standards as well.

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Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

■ Concise Concepts: This feature briefly summarizes an idea that is perhaps self- explanatory but important enough to emphasize. The idea is phrased in one or two sentences, which are broken down to highlight and clarify the concept in terms of who, what, when, where, why, and how.

■ Examples to Examine: This feature offers example documentation entries that demonstrate appropriate language style and content for documentation under discussion in the chapter section.

■ Excerpts That Explain: This feature shares relevant excerpts from sources such as the introductions and rationales for Joint Commission standards from the online E-dition and print version of the CAMBHC.

■ Focus on FAQs: This feature highlights frequently asked questions from The Joint Commission’s website. These are real questions asked by organizations and answered by members of the Standards Interpretation Group (SIG).

■ Instructive Infographics: This feature incorporates a graphic element, an infographic, or an illustration that makes important information clear. This feature is used to depict relationships, decision-making criteria, and processes.

■ Particular Points: This feature uses bulleted lists to highlight important information. These points are also used to explain fine points of distinction or interpretation of behavioral health care standards and related concepts.

■ Tools to Try: This feature includes checklists, forms, and other tools you can adapt for use in your organization. The feature includes a brief description of a tool and how it’s used; each tool can be found in the Appendix. More than two dozen downloadable, writable tools are provided in this book. Several documents are completed with fictional information to show you how a particular tool can be filled out and used effectively. Tools completed in this feature are available to download as blank tools. As noted, users of the e-book download from links, while users of the print edition go to a website address* provided to download the tools.

■ Successful Strategies: This feature, which appears toward the end of each chapter, contains information that expands beyond the topics covered in the chapter, with application in special programs/settings and strategies or tips that address related issues.

■ Scenarios to Study: This feature, which closes out each chapter, focuses on issues related to the standards and key concepts covered in the chapter. Each scenario describes a process or an approach to address the issues. It also includes a flowchart or diagram that illustrates application of the approach.

Examples to Examine

Tools toTry

INSTRUCTIVE INFOGRAPHICS

EXCERPTS that EXPLAIN

PARTICULAR POINTS

FOCUS ON FAQS?

CONCISE CONCEPTS

SUCCESSFUL STRATEGIES

Scenarios to Study

Introduction

Acknowledgments Joint Commission Resources (JCR) would like to thank the following organizations that supplied tools to adapt as part of the example set of tools in this book:

■ Chestnut Health Systems, Bloomington, Illinois

■ Columbia Lighthouse Project, New York, New York

■ Gallagher Services – Catholic Charities of Baltimore, Baltimore, Maryland

■ Lake County Health Department – Behavioral Health Services, Waukegan, Illinois

■ New Directions, Inc., Cleveland, Ohio

■ Summer Sky, Stephenville, Texas

Thanks also to The Joint Commission and JCR staff members who reviewed the manuscript of this edition and advised on its development.

Finally, our debt of gratitude is given to Lea Anne Stoughton for her excellent job in writing this publication.

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Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

Medical Staff Scope and Governance Chapter 1

Clinical documentation in behavioral health care tells a story. That story recounts the entire process of care, treatment, or services for an individual served, including any transfer or

discharge. The story must be founded on timely, complete, accurate data continuously collected and analyzed. This enables appropriate assessment of needs and an individu- alized plan for care, treatment, or services that reflects the individual’s progress.

Yet, although the plan is individualized, clinical docu- mentation involves recording information about the same core steps in every story. And those steps involve elements in a common cyclical process in the care, treatment, and services system. That system is supported by functions such as performance improvement, billing and reimbursement, and resource allocation that also require documentation. This chapter introduces you to these basic concepts of documentation in behavioral health care. Later chapters provide more detail about each core step.

A variety of graphics and tools will be presented in this chapter to help you understand the important ideas and

relevant standards . The chapter will end with a set of strategies for a particular

area and a scenario that shows you how the chapter concepts and standards are applied in a real-world situation .

Overview of Behavioral Health Care Documentation

Terms &topics glossary terms assessment; authenticate; behavioral health care; behavioral/ emotional functioning; clinical/case record; continuing care, treatment, or services; continuity of care, treatment, or services; data; discharge; discharge planning; documentation; goals; history and physical; individual served; interventionist; interventions; mock tracer; objectives; outcome; partial hospitalization program; performance improvement; plan for care, treatment, or services; progress notes; reassessment; referral; screening; services; transfer; trauma

chapter topics The Basics of Behavioral Health Care Documentation: RC.01.01.01, RC.01.02.01, RC.01.03.01, RC.01.04.01, RC.02.01.01, RC.02.04.01 The Cyclical Process of Care, Treatment, or Services: RC.01.01.01, RC.01.02.01, RC.01.03.01, RC.01.04.01, RC.01.05.01, RC.02.01.01, RC.02.03.07, RC.02.04.01 Core Steps of Care, Treatment, or Services: CTS.02.01.03, CTS.02.01.05, CTS.02.01.06, CTS.02.02.05, CTS.02.03.05, CTS.02.03.07, CTS.02.03.11, CTS.02.04.01, CTS.06.01.11, CTS.06.01.15 Support for the Care, Treatment, or Services System: LD.04.01.11, PI.01.01.01, PI.02.01.01, PI.03.01.01, RC.01.01.01, RC.01.03.01, RC.01.05.01 Effective, Quality Documentation: RC.01.01.01, RC.01.05.01, IM.01.01.01, IM.01.01.03, IM.02.01.01, IM.02.01.03, IM.02.02.01, IM.02.02.03, CTS.03.01.09, LD.04.01.07

Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

The information in this section helps you become familiar with the basics of behavioral health care documentation, particularly in relation to the clinical/ case record for the individual served. Issues addressed include ensuring the completeness, accuracy, authenti- cation, and timeliness of entries, including verbal orders, as well as ensuring that the record documents care, treatment, or services provided—including discharge information, if applicable.

The following are relevant standards for this section:

~ RC.01.01.01: The organization maintains complete and accurate clinical/case records.

~ RC.01.02.01: Entries in the clinical/case record are authenticated.

~ RC.01.03.01: Documentation in the clinical/care record is entered in a timely manner.

~ RC.01.04.01: The organization audits its clinical/ case records.

~ RC.02.01.01: The clinical/case record contains information that reflects the care, treatment, or services provided to the individual served.

~ RC.02.04.01: The organization documents the discharge information of the individual served.

SECTION SETS

The Basics of Behavioral Health Care Documentation

CONCISE CONCEPTS Documentation of Care, Treatment, or Services

Documentation affects

nearly every aspect of

care, treatment, or services

in behavioral health care organizations.

SECTION SETS | The Basics of Behavioral Health Care Documentation Chapter 1 Overview of Behavioral Health Care Documentation

INSTRUCTIVE INFOGRAPHICS The Five W’s of Behavioral Health Care Documentation To understand the basics of any concept, you often have to begin with some simple questions, like the “five Ws”: what, who, when, where, and why. The following chart answers these questions in regard to behavioral health care documentation. Answers may vary somewhat, however, depending on the specific program or setting.

WHAT is it?

• Generally refers to the clinical/case records of the care, treatment, or services and other clinical/case forms and notes

• Describes care, treatment, or services provided • Contains demographic information

WHO does it?

• Staff, behavioral health care professionals, or the multidisciplinary care, treatment, or services team (for example, caregiver staff, foster care workers, case managers, interventionists, drug and alcohol counselors, social workers, and clinicians such as physicians, clinical psychologists, clinical social workers, or clinical professional counselors)

• Competent external providers when specialty testing or examinations are required

• Individuals served when completing forms, questionnaires, and so on

WHEN is it done?

• Beginning and end of an experience of care, treatment, or services • Throughout the care, treatment, or services experience:

– On a regular basis – As needed – As quickly as possible to avoid delays in care, treatment, or services

WHERE is it done?

• In behavioral health care organizations: – By phone – In person

• In settings such as intensive outpatient/partial hospitalization programs, therapeutic schools, group homes, prisons, and other locations where behavioral health care is provided

• In the community (for example, assertive community treatment and community support services)

• In the individual’s home, when appropriate (for example, foster care and in-home services)

WHY is it done?

• Supports the care, treatment, or services process in the following ways: – Forms the basis for decisions about whether to provide care, treatment, or services

– If providing care, treatment, or services, determines which are needed and at what levels

– Justifies the need for care, treatment, or services – Confirms that care, treatment, or services were carried out according to an approved plan

– Captures necessary data to measure the general process and the care, treatment, or services outcomes

– Promotes continuity of care, treatment, or services • Complies with laws and regulations, including those related to

reimbursements

Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

INSTRUCTIVE INFOGRAPHICS Types of Behavioral Health Care Documentation The what list of documentation for behavioral health care clinical/case records can be quite extensive: You need to document all clinical/case information that reflects care, treatment, or services provided. The chart below shows the various types of documen- tation you’re required to document, per Joint Commission standards. Other types of documentation for support processes are touched on later in this chapter.

Demographic Information

• Name, address, date of birth, and sex of the individual served • Name and contact information for the individual’s family/guardian and/or significant others

(as appropriate) and any legally authorized representative • Preferred language and any special communication needs

Clinical/Case Information

Always Include Include If Applicable

• Reason(s) for care, treatment, or services

• Findings of required screenings, assessments, or reassessments

• Initial diagnoses, diagnostic impressions, or conditions

• Plan for care, treatment, or services and revisions to the plan

• Response to care, treatment, or services

• Findings of nonrequired screenings, assessments, or reassessments

• Orders for diagnostic and therapeutic tests and procedures, and their results

• Conclusions or impressions based on physical health screening and/or health and physical examination

• Diagnoses, diagnostic impressions, or conditions established during the course of care, treatment, or services

• Consultation reports • Observations relevant to care, treatment, or services • Emergency care, treatment, or services provided

before arrival or during care, treatment, or services • Progress notes • Medications ordered or prescribed • Medications administered (including strength, dose,

and route) • For intravenous therapy, access site for medication,

administration devices used, and rate of administration • Adverse drug reactions

Additional Information (if applicable and as needed)

• Advance psychiatric directives • Informed consent • Documentation of protective services • Documentation of consent for the following:

– Admission (if applicable) – Care, treatment, or services – Evaluation – Continuing care, treatment, or services – Research (if applicable)

SECTION SETS | The Basics of Behavioral Health Care Documentation Chapter 1 Overview of Behavioral Health Care Documentation

EXCERPTS that EXPLAIN A Complete Clinical/Case Record The “Record of Care, Treatment, and Services” (RC) chapter contains information about the components of a complete clinical/case record. A highly detailed document when seen in its entirety, the clinical/case record comprises all data and information gathered about an individual served from the moment he or she enters the organization to the moment of discharge or transfer [or throughout continuing care, treatment, or services]. As such, the clinical/case record functions not only as a historical record of an individual’s episode(s) of care but also as a method of communication among staff that can facilitate the continuity of care and aid in making decisions about care, treatment, or services.

—Overview in the “Record of Care, Treatment, and Services” chapter, Comprehensive Accreditation Manual for Behavioral Health Care and its online E-dition version

Additional Information (if applicable and as needed) continued

• Records of communication with the individual served • Documentation of involvement in care, treatment, or services by the individual served and

family/guardian and/or significant others (as appropriate) • Information on unusual occurrences, such as the following:

– Complications – Accidents or injuries to the individual served – Procedures that place the individual served at risk or cause pain – Other illnesses or conditions that affect care, treatment, or services – Death of the individual served – Indications for and episodes of special procedures, such as physical holding of child/youth, restraint, and seclusion

Discharge Information (if applicable)

• Discharge summary that includes the reason for acceptance for care, treatment, or services – Care, treatment, or services provided – Condition at discharge of the individual served – Information provided to the individual served or the family, such as the following:

⊲ Written discharge instructions ⊲ Medication regimen ⊲ Follow-up care, treatment, or services

Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

PARTICULAR POINTS Dated and Authorized Orders ■ The who and when of clinical/case record documentation need special attention when

individuals are dependent on authorized caregivers for getting timely care, treatment, or services. Both written and verbal orders need to be documented and authenticated in a timely manner, as defined in written policy and according to laws and regulations. You’re required to run audits on your organization’s clinical/case records to make sure that all orders are properly dated and authorized in a timely manner. In addition, your organization must define how frequently these audits happen. The diagrams below detail what authentication means and how verbal orders must be documented.

Larry Lancaster

Emily Fong

Only authorized staff make entries for written orders.

The author of each written order is identified.

Written order entries are countersigned when necessary.

Almira Jacard, MD 3/16/18

Verbal orders must be documented with the date and name of staff for the following:

Emily Fong 3/16/18

When the order was given

When the order was received

When the order was recorded

When the order was implemented

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