GOOD CLINICAL

DOCUMENTATION WITHIN CCS

Tamara Layne MS, OTR/L
Integrated Services Coordinator
Milwaukee County’s Community Access to Recovery Services (CARS) Branch
WHY IS CLINICAL DOCUMENTATION
IMPORTANT?
 WHY IS CLINICAL DOCUMENTATION
IMPORTANT? (CONTD.)
Documentation in the medical record:

 1) Supports the service provider in demonstrating the need for service

 2) Tracks the course of treatment and progress as it relates to the IRP

 3) Serves as a valid “receipt” of service for payer sources (insurance

companies, T-19, CCS, etc.)

 4) Protects and/or assists the provider to testify in situations where legal

action is being taken

 5) Is an essential communication tool for Recovery Team members

 KEY ASPECTS TO REMEMBER ABOUT
DOCUMENTATION
 Ifyou didn’t write it down, no one knows it
happened

 Your records might be viewed by:

 Judges
 Attorneys
 Consumer
 Guardian
 State
 MINIMIZE THE RISK OF LIABILITY
WARNING: INCLUDING ANY OF THE
FOLLOWING ITEMS IN YOUR DOCUMENTATION
MAY RESULT IN A LIABILITY ISSUE

1) Recording a “to do” item in the case file and not

following through

2) Negative, biased, or prejudicial language

 RECOMMENDATIONS FOR WRITING
GOOD CLINICAL PROGRESS NOTES
Make sure that your progress notes are:
 Factual

 Objective; unbiased
 Specific

 Clear and to the point

 Omit details of clients lives that do not have an impact
on care plan
 Avoid using medical diagnoses that have not been
verified and/or diagnosing if you are not qualified
According to DHS 36.18 (3)(e)….
The consumer’s service record MUST include:

 Service facilitation and progress notes

 Records of referrals to outside resources
 Descriptions of significant events, that are related to the
consumer’s care plan and contribute to an overall
understanding of the consumer’s ongoing level and quality of
functioning
 Evidence in the consumer’s progress, including response to
services, changes in condition and changes in services provided
 According to DHS 36.18 (3)(e)….
(Continued)

 Observation of changes in activity level or in physical,

cognitive or emotional status and details any referrals
 Case conference and consultation notes
 Service provider notes in accordance with standard
professional documentation practices
 DOCUMENTATION EXPECTATIONS
Milwaukee County will be regularly reviewing CCS documentation to
ensure compliance with outlined standards

When documentation is being reviewed, we expect

to see the following:
• Date and time service occurred
• Duration of the service (how many units)
• Nature of the contact i.e. face to face, phone call,
etc.
• What services (specifically) were provided
• Documented services justify the recorded duration
of the contact
 DOCUMENTATION EXPECTATIONS (Continued)
• Services are rehabilitative in nature

• The service(s) being provided link back to a specified goal(s) on the IRP

• Progress and changes in condition/service are clear and evident

• If there is an observation related to a mental, physical, or emotional change,

it has been addressed (or there is a plan to have it addressed)

• If an individual is mentioned in the case note, their relationship to the

consumer is also mentioned

• There is a plan at the end of each note indicating what will occur between
contacts followed by the “Next Contact” “Date”
CASE NOTES SHOULD DEMONSTRATE
THE CCS PROCESS
1) The steps in the CCS process should be clearly
documented from intake to discharge

2) Highlight the completion of important CCS related

paperwork

3) The more specific you are, the better reference

point your documentation serves
 NON-BILLABLE SERVICES

 Filing information in the client’s medical record

 Transportation without service provision
 Waiting in the lobby while the consumer is in an
appt.
 Outreach efforts prior to signing of Application and
Admission Agreement
 Recreational
activities – cannot bill for “Went to
the museum and had fun.”
1) What is the relation of this activity to the IRP?

2) How is it rehabilitative in nature?

 NON-BILLABLE ACTIVITIES (Continued)

 Unless an Abbreviated Assessment and IRP have been

created to address urgent and immediate needs, no
service delivery outside of screening/assessment, service
planning/facilitation should be provided before the
development of the IRP
 Going to the client home and the client is not there
 Calling the client and leaving a message (if the case note
is written this way)
 CASE NOTE SAMPLE:1
7/5/15 at 1:30 PM (10 units) This Care Coordinator Jen Jordan and Supervisor/Care
Coordinator Jessica Morton met
with Cl at the clinic to review the CCS program with Cl. CC provided Cl with information

regarding the CCS program/service array and Cl expressed interest. Cl was made aware that

he would need to transfer to a CCS therapist which he was agreeable to. During this

initial visit we completed the CCS application and signed the service agreement. We

reviewed and signed agency specific paperwork such as authorizations, No Contact Plan,

Identity Verification Form, HIPPA, Rights and Grievance, and weather related safety

information. CC collected information for the MH/AODA functional screen to determine

eligibility. CC notes that cl was pleasant and cooperative throughout this process. JJ
Electronic signature
 WHAT MAKES THIS AN EXCELLENT CASE NOTE?
• Date and time service occurred

• Duration of the service (how many units)

• What services (specifically) were provided

• Documented services justify the recorded duration of the contact

• If an individual is mentioned in the case note, their relationship to the consumer is

also mentioned

• If there is an observation related to a mental, physical, or emotional change, it

has been addressed (or there is a plan to have it addressed

• IMPORTANT: This is a CCS Intake note. The level of detail is perfect. Not all
expected case note components will always apply

• TO OBTAIN COMPLIIANCE ON THIS NOTE : Include nature of the contact i.e. face
to face, phone call, etc. and a plan at the end of the note as well as the “Next
Contact” “Date”
 CASE NOTE SAMPLE: 2
Goal on the IRP: MJ will meet with CPS who will support MJs goals and encourage socialization.

76/15 9:00AM (30 units)Certified Peer Specialist accompanied MJ to art therapy at St.
Luke's. Consumer
disappointed to find he had the wrong day. Consumer takes a lot of pride in his art work

and has some of it hung up in the waiting room. We then went to Omega for breakfast.
We
went to Walmart for a few things then went back to his home. We talked about the
usual
things one thing was his frustration with his family not accepting him. He had a smoker

move in below him which made him very angry because they had told him they wouldn't
do
that. I allowed him to vent and also pointed out that one can't change people unless

people want to change. Also, that he might have to accept the relationship as it is. I

spent over an hour trying to negotiate a good price from AT&T for a cable, computer
and
wireless. CPS was unable to get a better price. CPS sent AT&T to payee because they

quoted her a wrong price and CPS could not authorize the higher price
WHAT ARE THE ISSUES WITH THIS CASE
NOTE
• While their appears to be socialization going on during the contact, there is
not direct reference to what is being worked on

• There is also A LOT of took client here, took client there. CCS does not pay
for transportation. You need to clearly be providing a CCS service when you
are billing transportation time

 CPS attempted to negotiate an AT&T bill for the consumer 1)This is NOT
rehabilitative in nature as you are doing the service for the consumer nor is
this the CPS’s role as this is not written on the IRP
CASE NOTE SAMPLE 2: OTHER AREAS NEEDING
IMPROVEMENT FOR COMPLIANCE
• What services (specifically) were provided

• Documented services justify the recorded duration of the contact

• Services are rehabilitative in nature

• The service(s) being provided link back to a specified goal(s) on the

IRP

• There is a plan at the end of each note indicating what will occur
between contacts followed by the “Next Contact” “Date”
 CASE NOTE SAMPLE: 3
 7/7/15 11:00 AM (4 units)HV w/ Ms. Jones. She looked awful-
clothes dirty, hair dirty, hair messed up. She stunk. The apartment
smelled liked pee. As usual, she complained of not feeling good.
Told her to go see her doctor. Will call SHC coordinator to find out
if she knows anything about why Mrs. Roberts stinks.

 FIRST MAJOR ISSUE WITH THIS NOTE: Unprofessional, biased and

disrespectful.
WHAT ARE THE ADDITIONAL ISSUES WITH
THIS CASE NOTE?

• What services (specifically) were provided

• Documented services justify the recorded duration of the contact

• Services are rehabilitative in nature

• The service(s) being provided link back to a specified goal(s) on the IRP

• Progress and changes in condition/service are clear and evident

• There is a plan at the end of each note indicating what will occur
between contacts followed by the “Next contact” “date”
 CASE NOTE SAMPLE: 4
IRP Goal: Jack wants someone to assist him in taking his medications and understanding what his
medications are for as well as identifying the side effects of his medications
7/14/15 8:30 AM (5 units) I coordinated with Recovery, Inc. to set up the delivery of Jack’s
medications. Jack
was in a good mood and I watched Jack fill his medication strips for the next week.
Jack had mentioned that he would like to keep his medication fill date on Wednesdays
in the AM. I did not see a problem with this and told him this would work well but I had
to make sure it was alright with Recovery, Inc. Jack took his AM medication in front of me.
Jack reported that he had missed a dose of medication over the weekend due to forgetting
and that he felt his
Symptoms gradually returning. I encouraged Jack to contact his care coordinator if the
symptoms got
any worse and he felt he needed any kind of intervention. Jack stated that he felt
that now that he was back on track with his medication and that he would be fine.

Plan:
Jack and I will meet again on June 24, 2015 to give him medication for the next week.
WHAT MAKES THIS AGOOD CLINICAL CASE
NOTE?
• Date and time service occurred

• Duration of the service (how many units)

• Nature of the contact i.e. face to face, phone call, etc.

• What services (specifically) were provided

• Documented services justify the recorded duration of the contact

• Progress and changes in condition/service are clear and evident

• If there is an observation related to a mental, physical, or emotional change, it has been addressed

(or there is a plan to have it addressed)

• If an individual is mentioned in the case note, their relationship to the consumer is also mentioned

• There is a plan at the end of each note indicating what will occur between contacts followed by the

“Next contact” “date”

• From a compliance standpoint, the majority of good case note elements are present. As far as service delivery, this note would’ve been better if medication

education was occurring and documented, as this is listed on the IRP as being a desire of Jack’s to learn about his medications
• The other question is related to Jack wanting a contact changed to a certain day, and the provider needing to check-in with Recovery, Inc. to make sure this is “alright.” CCS is a consumer-driven program. If a consumer wants to change a day or the frequency of a contact, service providers do not need to ask permission from the care coordination
team to honor this, they simply need to inform them that this is what the consumer wants to do so they are aware and can adjust accordingly
CASE NOTING IN PROVIDER CONNECT

 All CCS providers will enter case notes into Provider

Connect
 Billing is attached to your case note in PC so billing
won’t need to be entered separately
 PC will allow the opportunity for CCS providers on a
designated Recovery Team to review each other’s case
notes
 CASE NOTING IN PROVIDER CONNECT

 Special consideration for Psychotherapy notes- Psychotherapy

notes need to strictly meet the standards outlined in 36.18 (3)(e).
Under this service, the level of detail typically kept in a therapist’s
record does not need to be entered into Provider Connect. Due to
HIPPA and privacy standards, a Release of Information needs to be
obtained from the consumer in order for a provider on the CCS
Recovery Team to view psychotherapy notes
 TIPS AND TECHNIQUES TO CONSIDER
 Carry a note pad with you at all times

 Keep a note pad near your phone

 Save a half hour each day to do case noting

 Set aside paperwork days and put it on your calendar

 Talk to a co-worker who does case noting well to learn from him/her

 Secure protected time

 Is it possible to turn your phone off for a half hour

 Say “no” to other tasks

KEY POINTS: IMPORTANCE OF GOOD
CLINICAL DOCUMENTATION
Good Clinical Documentation:
 Provides a Picture of the Recovery Process

 Supports the need for services

 Provides Protection

 Keeps you focused on what you are working on and why

THANK YOU