Treatment Planning and Progress Notation (JCAHO)

Treatment plans need to utilize assessment information, describe client problems in behavioral terms, specify in measurable steps the objectives that have been individually selected to help clients reach identified goals. This session equips providers to identify what is medically necessary, to allocate and utilize client resources and strengths, to focus case management, and to be familiar with the language of case documentation including involvement of the client in the planning process. Instruction includes an overview of assessment materials used to develop treatment plans, writing an integrated summary, interdisciplinary treatment planning, developing and writing problem statements, goal statements, determining objectives, interventions and progress notation. Information about JCAHO accreditation standards and utilization review requirements for documentation in today’s managed care environment is integrated into a hands-on practice session that makes treatment planning and other documentation painless and easy to do. This class is a must for anyone who needs to learn how to better articulate practice activities. Risk management and legal issues are also discussed.

Objectives:

1. Participants will be able to identify the four components of a comprehensive interdisciplinary treatment plan

2. Participants will be able to describe how psychological measurement tools are used in treatment planning, such as SASSI, ASI, & Mental Status Exam

3. Participants will be able to develop a master problem list from an interdisciplinary assessment summary

4. Participants will be able to formulate individualized problem statements from a master problem list.

5. Participants will be able to develop long term and short-term measurable goals for problem statements

6. Participants will be able to identify objectives, interventions, and deadlines for review for long and short-term goals.

7. Participants will be able to write behavioral treatment goals.

8. Participants will able to differentiate the following notation types; Screening, Assessment, Treatment Plan, Individual Progress, Group

9. Progress, Case Management Notes, Staffing Progress, Problem Care Monitoring, Discharge Review

10. Participants will be able to discuss the standards as put forth by the Joint Commission for Accreditation of Health Organizations for treatment planning and progress notation.

Training Agenda:

Hour One: Present components of assessment that are used in treatment planning Overview psychological measurement tools used for assessment Practice skills in writing integrated summaries

Hour Two: Overview the components of a comprehensive interdisciplinary treatment plan Learn about and practice making master problem lists

Hour Three: Practice writing problem statements Practice batching problems and learning coding options for problem management

Hour Four: Identify and writing goal statements Criteria for optimal goal statements.

Hour Five: Development of objectives Writing objectives Individualizing objectives Identifying and writing interventions

Hour Six: Progress Notation types

Hour Seven: Overview JCAHO standards for treatment planning, Continuum of care, and patient rights Q & A

Methods: Pretest, Study guide, National Exam and evaluation