Documentation Formatting

What are the sections of the note format?
Problem, Needs Addressed, Next Steps/ Care Plan
Behavior, Intervention, plan
Needs Addressed, Next Plan/ Care Plan
Next Steps, Problem, Needs Addressed
What information is included in the Needs addressed section?
The needs addressed, interventions implemented, and the plan
Progress the client has made, interventions implemented, and next steps
Problem addressed, interventions implemented , client progress/ response
Interventions implemented, client progress, plan
What billing code requires a care plan?
Rehab- H2015
Collateral- 90887
TCM-T1017
Plan Development- H0032
Which answer best represent how a problem is written?
Client isolates daily due to depressed mood.
Client engages in physical aggression.
Client will decrease suicidal statements from 5 times a week to 0 times a week?
Client will decrease manic episodes.
What are problems?
Behaviors
Symptoms
A problem is a symptom, behavior, need, and/or risk factor.
Linkages
Which answer reflects a Care Plan?
Services will continue to address Bipolar I Disorder.
TCM services will continue to address client's homelessness
Homelessness
Client will decrease abuse of methamphetamine from 6 times a week to 2 times a week.
Choose the best answer that describes the information in the Next Steps section.
Plan
Doctor's recommendation
Clin./CM and client's plan for next session, Care plan
Where the next session will be held.
Write a rehab note for a client with the following problem, Client engages in verbal aggression. Make sure to include all part of the note format.
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