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Progress Notes and Progress Notes Instructions

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Contract provider progress/session notes are critical in assessing treatment goals and helping determine current and future needs. Progress/session notes serve as monitoring documentation in medical/clinical records as mandated by Joint Commission on Accreditation of Health Care Organization (JCAHO), Medicaid, Missouri Department of Mental Health and other agencies. 

Progress/session notes are created when a client begins treatment with a provider. A closing note is documented when a client terminates services. 

All progress/session notes are reviewed by BJCBH staff. The HIMS monitors the notes for timeliness and required elements. Clinical staff review notes to determine a client's progress toward treatment and goals, and future needs. Incomplete progress/session notes are returned for completion or correction. Progress/session notes are essential for staff clinical functions. Documentation and reviews are attached to provider progress/session notes.

When complete, BJCBH medical records staff input the progress/session note data into an information management system. This system provides information on a client's progress, use of treatment services, and compliance with treatment. 

Progress/Session Note Instructions
BJCBH uses progress/session notes to facilitate communication between physicians, therapists and the case management staff. Upon receipt, the notes become part of the permanent medical record. A new note is required for each visit.

The case manager uses the note:

  • To determine which services are needed to reach consumer treatment goals 
  • To provide staff with information regarding progress in treatment, current medications, responses and side effects
  • To document current diagnoses
  • To communicate and document recommendations for treatment and continued care

The case manager reviews the note and updates the treatment plan. This regular exchange benefits the treatment team by addressing concerns from other areas of the client's life.

Elements of the progress report and closing summary are entered into a data base. This allows an aggregate look at client data across time and facilitates decisions about types of services needed.

Instructions

  • The progress/session note is completed for each visit, based on information gathered during the most recent visit and interim history
  • The progress/session note must be mailed to BJCBH within 30 days of delivery of the service; a note also must be mailed if the client failed to keep appointments; non-compliance is pertinent to the provision of services
  • Notes should be written legibly in permanent black ink; they are part of the BJCBH permanent clinical record; white-out may not be used
  • The progress/session note may be maintained on your computer and a printed copy mailed to BJCBH
  • The progress/session note is a required document; failure to provide it may result in penalties, including removal from the BJCBH network of providers

An incomplete progress/session note will be returned. Corrections must be made and the report returned to BJCBH within five working days.

Include a complete Axis I-V diagnosis in a progress note at least once a year.

Axis I-III

  • Print or type the current working diagnoses for Axis I-III
  • Use DSM-IV-R terminology
  • Write "NONE" if there is no diagnosis 
  • Do not code; numerical codes cannot be accepted
  • Do not use abbreviations
  • Write out all diagnoses

Axis IV: Psychosocial and Environmental Problems

  • Problems with Family -- Death of a family member; health problems in family; disruption of family by separation, divorce or estrangement; removal from the home; remarriage of a parent; sexual or physical abuse; parental overprotection; neglect of child; inadequate discipline; discord with siblings; and birth of a sibling
     
  • Problems Related to the Social Network -- Death or loss of a friend, social isolation, living alone, difficulty with acculturation, discrimination and adjustment to life cycle transition
     
  • Educational Problems -- Illiteracy, academic problems, discord with teachers or classmates, and inadequate school environment
     
  • Occupational Problems -- Unemployment, threat of job loss, stressful work schedule, difficult work condition, job dissatisfaction, job change, and discord with boss or co-workers 
     
  • Housing Problems -- Homelessness, inadequate housing, discord with neighbors or landlord, and unsafe neighborhood
     
  • Economic Problems -- Extreme poverty, inadequate finances and insufficient welfare support
     
  • Problems with Access to Health-Care Services -- Inadequate health care, transportation to health-care facilities, unavailable and inadequate health insurance 
     
  • Legal Problems -- Arrest, incarceration, litigation and victim of a crime
     
  • Problems with Daily Living Skills --  Ability to groom, manage personal hygiene, handle individual finances, use community resources, perform household chores and activities appropriate to the individual's age and social role functioning (please rate as 1 = mild, 2 = moderate or 3 = severe)
     
  • Other Problems -- Exposure to disasters, war, hostilities, discord with nonfamily caregivers such as social workers and physicians, and absence of needed service

Axis V
Global Assessment of Functioning (mGAF)

  • Rate the current mGAF based on the most recent visit and rate the highest mGAF for the previous year, e.g., 45/63 when the current mGAF is 45 and the highest in the previous year is 63
  • For children four to 16, use the Children's Global Assessment Scale

Axis V for Children
Children's Global Assessment Scale -- For Children 4-16

Rate the subject's most impaired level of general functioning for the specified time by selecting the lowest level that describes his or her functioning on a hypothetical continuum of health --illness. Use intermediary levels (35, 58 and 62).

Rate the child's functioning regardless of treatment or prognosis. The examples of behavior provided are only illustrative and are not required for a particular rating.

Specified period: one month

100-91 -- Superior Functioning in All Areas -- At home, at school and with peers; involved in a wide range of activities and has many interests; has hobbies or participates in extracurricular activities or belongs to an organized group; likable, confident; everyday worries never get out of hand; doing well in school; no symptoms

90-81 -- Good Functioning in All Areas -- Secure in family, school and with peers; there may be transient difficulties and everyday worries that occasionally get out of hand; mild anxiety associated with an important exam; occasional "blowups" with siblings, parents or peers

80-71 -- No More Than Slight Impairment in Functioning -- At home, at school or with peers; some disturbance of behavior or emotional distress may be present in response to life stresses -- parental separations, deaths, birth of sibling, but these are brief and interference with functioning is transient; such children are only minimally disturbing to others and are not considered deviant to those who know them

70-61 -- Some Difficulty in a Single Area, But Generally Functioning Pretty Well -- Sporadic or isolated antisocial acts -- occasionally playing hooky or committing petty theft; consistent minor difficulties with school work; mood changes of brief duration; fears and anxieties that do not lead to gross avoidance behavior; self-doubts; has some meaningful interpersonal relationships; most people who do not know the child well would not consider them deviant, but those who do know them well might express concern

60-51 -- Variable Functioning with Sporadic Difficulties or Symptoms in Several, But Not All, Social Areas -- Disturbance would be apparent to those who encounter the child in a dysfunctional setting or time, but not to those who see the child in other settings

50-41 -- Moderate Degree of Interference in Functioning in Most Social Areas or Severe Impairment of Functioning in One Area -- Suicidal preoccupation, school refusal and other forms of anxiety; obsessive rituals, major conversion symptoms, frequent anxiety attacks, poor or inappropriate social skills; frequent episodes of aggressive or other antisocial behavior with some preservation of meaningful social relationships

40-31 -- Major Impairment in Functioning in Several Areas and Unable to Function in One of These Areas -- Disturbed at home, at school, with peers or in society at large -- persistent aggression without clear instigation; markedly withdrawn and isolated behavior due to either mood or thought disturbance; suicidal attempts with clear lethal intent; such children are likely to require special schooling

30-21 -- Unable to Function in Almost All Areas -- Stays at home, in ward or in bed without taking part in social activities; or severe impairment in reality testing or serious impairment in communication -- sometimes incoherent or inappropriate

20-11 -- Needs Considerable Supervision to Prevent Hurting Others or Self -- Frequently violent, repeated suicide attempts; or to maintain personal hygiene or gross impairment in all forms of communication -- severe abnormalities in verbal and nonverbal communication, marked social aloofness

10-1 -- Needs Constant Supervision -- 24-hour care due to severely aggressive or self-destructive behavior; or gross impairment in reality testing, communication, cognition, affect or personal hygiene

Abnormal Involuntary Movement Scale

The Abnormal Involuntary Movement Scale (AIMS) is a standardized instrument used to screen and document possible side effects from antipsychotic medications.

  • It is mailed to providers twice a year, during January, February, March, July, August and September
  • In case of abnormal findings, physicians should reassess the medication regimen and make a referral for a neurological evaluation

For patients on an antipsychotic: 

  • The physician assesses and documents for involuntary movement disorder and returns a completed AIMS form
  • When there are abnormal involuntary movements, the need for continuing the antipsychotic should be evaluated and consent obtained from the patient for course of action

With worsening involuntary movement disorder, the treating psychiatrist assesses likely causes and refers for further assessment, as needed.

For patients not on an antipsychotic:

  • The physician checks the box "not on neuroleptics" and returns the AIMS

 


    
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