CADC – Documentation

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CADC – Documentation Roles of documentation ✔✔1. clinical tool 2. continuity of care 3. legal document 4. accountability 5. quality assurance Documentation as a clinical tool ✔✔chronol ... ogically details the condition of the client receiving services, why the services were needed, services provided who delivered the services, and outcomes achieved. - used in supervision - most important skill in assuring continuity of care Documentation as means to ensure continuity of care ✔✔ensures continuity of care, regardless of counselor availability, changes in counselor or service provider or subsequent readmission for services. - EASES the TRANSITION PROCESS ensuring pertinent info is available to receiving counselor/program Documentation as a legal document ✔✔records both counselor and client input, including what did/did not work. - portions of clt record may be requested by courts if clt is legally involved or in cases where the clt brings legal proceedings against a counselor/program Documentation as accountability ✔✔recording information that is used for billing purposes, financial audits or reviews to ensure compliance with various standards. - document time, date, duration & type of insurance Documentation for quality assurance ✔✔the clt record provides documentation for quality assurance reviews including utilization review, peer review, and clinical supervision. - processes assess if the type, intensity, duration of services are appropriate for client's condition and if documents meet regulatory and agency expectations. In IL, how long are treatment records retained? ✔✔5 years after discharge, excluding the accounting of disclosures protected by HIPPA which must be retained for 6 years. In IL, How long are medical records detained? ✔✔7 years Screening ✔✔Occurs at INITIAL CONTACT, purpose is to gather enough preliminary information about the clt to evaluate their need for services, eligibility for services, and appropriate level of care/service placement. - Focuses on CURRENT INFO regarding the PRESENTING PRBLM and the PRBLM ACUITY that resulted in the clt seeking or being referred to treatment Elements of screening documentation ✔✔1. Referral source 2. Presenting problems/problem acuity 3. Background information (vocational, legal, family, living environment) 4. Emotional/mental status (degree of danger to self/others, ability to participant in tx) 5. Client strengths and preferences 6. Recommendation for assessment or other referral Comprehensive assessment ✔✔biopsychosocial assessment is the foundation which the clt record is built and entails data gathering, analysis, and identification of problems/strengths which provide the basis for treatment. - multiple sources of information used in the development of biopsychosocial assessment such as client self report, info from parents/spouses/family/probation officers/teachers/pcp and results of medical/psychological tests. Based on counselor's observations and experience, a clinical summary is formulated. [Show More]

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