Progress Notes | POC's | Assessments | Diagnosing | Hodgepodge |
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What is the new timeliness standard?
0-3 Business Days
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True
True OR False
Plans of Care's must be updated at least annually or when there is a significant change in the consumer. |
-Description of Symptoms
-Description of Functional Impairment -Events/Stressors that led Client to Treatment
What are the 3 main boxes on the first page of a mental health assessment at Kings View?
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DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
This is the diagnostic tool published by the American Psychiatric Association and serves as the principal authority for psychiatric diagnoses.
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Day 60 (Outpatient)
What day does an initial POC need to be finalized by?
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What does BIOP stand for?
Behavior-
Intervention- Outcome- Plan- |
Client and a Provider
Who is involved in completing a POC?
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Annually (at minimum)
How often do MH assessments need to be completed by staff?
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"Z codes" related to psychosocial factors
What codes are found on Axis IV?
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"Lockout" Periods
A situation/circumstance when we are not able to bill for SMHS.
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True
True OR False
Progress notes describe: -how services reduce impairment -restoration of functioning -or prevented significant deterioration in an important area of life functioning |
No, it is important to have the client participate in the process and collaborate with provider what the focus of treatment will be.
Dr. Rogers saw a client, but she forgot to review a POC that was expired. Can she just review the POC herself cause after all she knows what the client needs to work on so she can bill for the day's service cause she needs the productivity?
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Mental Status Exam (MSE)
Affect, Speech, Thought Content, Cognition are part of which section of an assessment?
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True
True OR False
When completing a diagnosis form it is important to summarize symptoms, precipitating factors, onset, duration and intensity to support the diagnosis. |
True
Licensed Practitioner of the Healing Arts (LPHA): Physician/Medical Doctor (Licensed) PhD (Licensed, Registered or Waivered) PsyD (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) MSW (Licensed, Registered or Waivered) Professional Counselor (Licensed, Registered or Waivered) Registered Nurse (if Psych Masters, CNS, or NP; Licensed, Registered or Waivered)
True OR False
You cannot conduct a Mental Status Exam (a primary element of assessment/diagnosis) unless you are a LHPA. |
What is "medical necessity"?
This term refers to the decision by a health plan (i.e., Medi-Cal) that your treatment is necessary for a qualified diagnosis.
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True
True OR False
Objectives are to be "observable & measurable" that relate back to presenting problems & diagnoses, which are integrated to include all services provided. |
What is a case disposition?
The following is an example of:
Clt meets criteria for PTSD as evidenced by her recent sexual assault that has led to her experiencing recurrent nightmares and flashbacks of the event that occurrent 5 months ago, avoidance going to school at times where the assault occurred, feeling isolated and difficulty recalling pieces of the assault, hypervigilant at night, which has impacted her not going to evening classes and lowered grades this past semester. She would benefit from processing past trauma to relieve symptoms & recommended to attend Seeking Safety group in order to learn skills to deal with trauma. She denied participation in med services, but was encouraged to discuss any changes regarding intensity of symptoms and managing them with medication with her PCP. She was offered individual therapy sessions & discussed preference of gender, location and licensing status. |
Axis III
If a client identified/reported there was a medical condition in their assessment, which Axis would you list that on in the diagnosis form?
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4 Required Elements: (1) Covered Mental Health Diagnosis; (2) Functional Impairments; (3) Treatment Interventions; (4) Not Responsive to Physical Health Care Treatment
What are the 4 elements of medical necessity?
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False
All are needed for the exception of the picture of the provider on their last vacation
True or False
When there is more than 1 staff member providing a service to a consumer these components need to be included in the note: -each person's involvement in context of mental health needs of the consumer -# of minutes used by each staff member providing the service -signature of staff providing service -picture of the provider on their last vacation |
-Specific, Observable, and/or Quantifiable Goals
-Treatment Objectives related to the consumer's mental health need & functional impairment -Proposed type(s) of interventions/modality with description how it will be provided. -Consumer and Provider Signature
List at least 2 elements that would be included in a POC.
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•Presenting Problem •Relevant conditions and psychosocial factors •Mental Health History •Medical History •Medications •Substance Exposure/Substance Use
•Strengths Risks •A mental status examination •Most current ICD 10 diagnosis (and should also include corresponding DSM Diagnosis) •Additional clarifying information, as needed
List at least 5 requirements you will find in an assessment.
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“Deferred” or “by history”, A stand-alone “Rule Out” diagnosis, Provisional Diagnosis (either depression or bipolar), “V” codes, Mental Retardation (aka Intellectual Disabilities), Learning Disorders, Motor Skill Disorders, Communication Disorders, Delirium, Autism Spectrum Disorder, Antisocial Personality Disorder
List at least x3 excluded diagnoses we are unable to see at Kings View.
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What is "The Golden Thread"?
What is the phrase that refers tying/linking the elements listed below?
Clinical Practice=assessment-plan development-interventions Medi-Cal Logic=diagnosis & functional impairment-treatment plan-interventions |