Documentation: Goals, Intake Notes, And Beyond
Documentation: Goals,Intake Notes, and BeyondAugust 12, 2016
Agenda Session I: Goals and Action Plans– Review of May Learning Collaborative Setting the Stage SMART Goals Action Plans– Practice Activities Session II: Progress Notes– Intake Notes– Progress Notes– Practice Activities
Goals vs Action PlansTest Your Knowledge
Vision, SMART Goals, & Action PlansVisionGoal 1Action Step 1Action Step 2Goal 2Action Step 1Goal 3Action Step 1Action Step 2
Key Elements of Person-CenteredRecovery PlanningOutcomesAction PlansSMART GoalsStrengths and Concerns/NeedsParent/Youth's h
Setting the Stage Approach– Active listening skills Assessment– Reveals what is happening for families Understanding– Reveals why it is happening, and futuredirections Prioritization– Focusing on most pressing issues
Parent/Youth’s Vision Broadlystated and reflects the big picture. Identifies the desired destination and whatthe destination looks like. Meaningful to the individual. Easily understood by any reader.
Clarifying the Vision Howwill you know that you have achievedyour goal? What would it look like? What would you like to see happen as aresult of participating in these services? What have you tried in the past?– How did it work? Whathas been in the way of making thechanges you would like to see?
What Might Success Look Like?9Stated Need/Concern“I want to communicate better”“I need to get my anger undercontrol”“I want to do better in school”“I have no concerns and goals”“I want to be a better parent”What might a possible goal be?
What Might Success Look Like?10Stated Need/ConcernWhat might a possible goal be?“I want to communicate better” I will talk to my son every day whenhe comes home from school. Wewill have family dinners together atleast twice per week.“I need to get my anger undercontrol”“I want to do better in school”“I have no concerns and goals”“I want to be a better parent”
What Might Success Look Like?11Stated Need/ConcernWhat might a possible goal be?“I want to communicate better”I will talk to my son every day whenhe comes home from school. Wewill have family dinners together atleast twice per week.“I need to get my anger undercontrol”“I want to do better in school”“I have no concerns and goals”“I want to be a better parent”
What Might Success Look Like?12Stated Need/ConcernWhat might a possible goal be?“I want to communicate better”I will talk to my son every day whenhe comes home from school. Wewill have family dinners together atleast twice per week.“I need to get my anger undercontrol”I will take a break when I feeltriggered and speak calmly to mychild when frustrated.“I want to do better in school”“I have no concerns and goals”“I want to be a better parent”
What Might Success Look Like?13Stated Need/ConcernWhat might a possible goal be?“I want to communicate better”I will talk to my son every day whenhe comes home from school. Wewill have family dinners together atleast twice per week.“I need to get my anger undercontrol”I will take a break when I feeltriggered and speak calmly to mychild when frustrated.“I want to do better in school”“I have no concerns and goals”“I want to be a better parent”
What Might Success Look Like?14Stated Need/ConcernWhat might a possible goal be?“I want to communicate better”I will talk to my son every day whenhe comes home from school. Wewill have family dinners together atleast twice per week.“I need to get my anger undercontrol”I will take a break when I feeltriggered and speak calmly to mychild when frustrated.“I want to do better in school”I will increase my math grade by 5points in the next 3 months.“I have no concerns and goals”“I want to be a better parent”
What Might Success Look Like?15Stated Need/ConcernWhat might a possible goal be?“I want to communicate better”I will talk to my son every day whenhe comes home from school. Wewill have family dinners together atleast twice per week.“I need to get my anger undercontrol”I will take a break when I feeltriggered and speak calmly to mychild when frustrated.“I want to do better in school”I will increase my math grade by 5points in the next 3 months.“I have no concerns and goals”What questions might you ask?“I want to be a better parent”
What Might Success Look Like?16Stated Need/ConcernWhat might a possible goal be?“I want to communicate better”I will talk to my son every day whenhe comes home from school. Wewill have family dinners together atleast twice per week.“I need to get my anger undercontrol”I will take a break when I feeltriggered and speak calmly to mychild when frustrated.“I want to do better in school”I will increase my math grade by 5points in the next 3 months.“I have no concerns and goals”What questions might you ask?“I want to be a better parent”What might success look like?
Strengths and Concerns/Needs Strengthsare actively used to drive andshape recovery planning. To quickly identify concerns/needs, ask:What’s keeping them stuck? Capitalizing on strengths and accountingfor concerns/needs illuminates how youwill achieve an identified goal. Focus on factors that are related to themission/services of your FRC.
SMART GoalsS Simple, straightforward, specificM MeasurableA Attainable, action-orientedR Relevant (to goal and stage of change)T Time-bound
Effective SMART Goals Meaningfulto the individual Easily understood by any reader Effective in tracking progress Encourage the person to try new skills Contains ONE behavior that works towardachieving the vision. Are not limited to service participation.
Formula for SMART GoalsWithin[amount of time (time-bound)],[insert name] will have improved[insert documented concern/need(relevant)], as evidenced by [insert ameaningful change in functioning orbehavior that is related to the vision(measurable and action oriented)].
Limit Your Scope of Action Choose1-2 goals. Identifykey strategies and tasks that willhelp them reach goal. Besure the key strategies have a directconnection to what you want to achieve. Decidethe WHO, WHAT, and BY WHEN ofeach task.
Goals to SMART Goals Better Communication: I want to talk to myson every day when he comes home fromschool. I would like to have family dinnerstogether at least twice per week.Controlling Anger: I want take a break when Ifeel triggered and speak calmly to my childwhen frustrated.Better in School: I hope to increase my Mathgrade by 5 points.
Action Plans aka Services Action Plans serve as a contract for who is responsiblefor what actions, including the person receiving servicesand natural supports, that is, supports that they alreadyhave in place.Action Plans include services which:– Are tailored to the stage of change/recovery– Describe medical necessity by clearly identifyinghow recommended services can help the individualovercome specific concerns– Are connected to a specific objectiveAction Plans from natural supports are not services.Focus on factors under your control.
Service Action Plans – 5 Ws Must specify:– WHO will provide the service, i.e. name and job title– WHAT: The NAME of the service, e.g., basic livingskills training, AND the modality in which the servicewill be provided, e.g., individual sessions or in group– WHEN: The SCHEDULE of the service, i.e. the timeand day(s)– WHERE the service is being provided– WHY: The intent and purpose of theservice/intervention
SMART Goals Action Plans BetterCommunication Controlling Anger Better in School
Common Errors: Goals and ActionPlans SMART Goals–––– Don’t support the visionNot measurable or behavioralAction Plans become SMART GoalsNot time-framed or generically time framedAction Plans (Also in a SMART format)–––––Purpose not includedFrequency, intensity, and duration not includedDon’t reflect multidisciplinary activityDon’t include natural supportsDon’t link to the goal
Quick Review Parent/Youth's Vision:– What the person would ultimately like to achieve– The desired outcome SMART Goals:– What the person will do, change, or accomplish to achieve Vision– Measurable changes the person will make and skills to be gained Action Plans (in SMART format):– Services and supports that help person achieve Parent/Youth'sVision and SMART Goals– Not limited to providers; may include actions by person, familymembers, and support network Remember, services are not SMART Goals!
The Petersons As a Family Advocate, you meet Ms. Peterson in her home for thefirst time to complete an intake and gather more information on thethings she would like you to assist her with. Ms. Peterson is amother of 5 children ranging from the ages of 5 thru 19 years ofage. She shares with you that she is extremely concerned about her15 year-old daughter, Skyler. Skyler used to be in the church choirand assist the pastor with the Youth Council but about a year ago,she stopped wanting to go to church and began hanging out witholder adolescents. Skyler has been suspended on numerousoccasions from school for cursing at the teachers and 2 months agoshe went to court for assault charges against another student. Ms. Peterson shared feeling extremely overwhelmed and notknowing what services are available for Skyler and her anger issues.Ms. Peterson also stated that her landlord is trying to bully her intomoving out of her apartment in order to rent it out at a higher rate.Ms. Peterson stated she really wants to look for legal help to takeher landlord to court. Ms. Peterson also shared wanting to betterherself and her family’s economic situation by going back to schoolfor her Associate’s Degree.
Ms. Peterson Whatis a possible vision statement for Ms.Peterson? Make two goals that relate to her visionstatement and the background informationthat you have. Come up with 2 action plans for each goal.
Outcomes Outcomesare the identified and agreedupon end point for services. Tracking outcomes provides anopportunity for the family member/youthand advocate to evaluate how things aregoing on a regular basis. How will you know when it is time to talkabout discharge with Ms. Peterson?
Intake Note Intake set the stage for all futuredocumentation.Almost everything you need to write in an intakenote is already completed in eCOMPAS duringthe assessment.Include information to make it all flow togetheras a narrative.
Intake Notes: What goes in? GenTab:– where they heard about the FRC– Initial reason for coming in HistoryTab:– Parent: history of mental illness and/orsubstance abuse– Youth: MH diagnosis, History of Sub. Ab,number of times youth (Psych ER, arrest,suspension, etc.)
Intake Notes: What goes in? Goals:– Strengths– Needs– Goal, action plans, and date of anticipatedcompletion Assessment:– FES score and notable outcomes (positive androom for growth)
Progress Notes Providesan opportunity for family/youthand advocate to evaluate how things aregoing on a frequent and regular basis. Documents the continued medicalnecessity of the services being provided. Summarizes the period of time reviewed. Can be considered a “mini” plan review.
Medical Necessity MedicalNecessity“ shall mean payment of part or all of the cost of medically necessaryservices, as authorized by Medicaid, which are necessary to prevent,diagnose, correct or cure conditions in the person that cause acutesuffering, endanger life, result in illness or infirmity, interfere with suchperson’s capacity for normal activity, or threaten some significant disabilityand which are furnished to an eligible person in accordance with this titleand the regulations of the department.”What?In plain English, it means that your services have to be described in away that prove they should help your parent/youth achieve theirgoal while also connecting with the overall vision.
Progress Notes Providesan opportunity for family/youthand advocate to evaluate how things aregoing on a frequent and regular basis. Documents the continued medicalnecessity of the services being provided. Summarizes the period of time reviewed. Can be considered a “mini” plan review.
Elements of a Progress Note Description of progress made and/challengesencountered in achieving goals/objectives.Discussion on the usefulness of services andother interventions in achieving goals.Documentation of any significant events in theperson’s life, both accomplishments anddifficulties.Follow-up on issues identified in previousdocumentation.Next steps.
Tips for a Successful Progress Note Objectivenot Subjective Thorough, yet concise Written soon after interaction withyouth/parent to ensure accuracy Connects to parent/youth’s strengths Can be understood by and appropriate forany reader (coworker, family/youth, andauditor)
SOAPD Strengths observed Objective account of the interaction Assessment of the situation/individual Plan (progress toward specific goal) Data or new information gathered
Progress Note ElementsIncludes clear link to goals and actionplans.Describes progress made and/orchallenges (lack of progress)encountered in achieving action plansand/or goals.Includes a summary/discussion ofmeeting, recent services andinterventions provided since the lastnote.Identification of any necessarychanges to the goals/action plans.Documentation of any significant lifeevents (successes and/or barriers)Addresses any outstanding issues fromprevious progress note.Strengths observed.Date of service, time spent, andlocation.Progress note is signed and dated.FullyPartiallyAbsentNotes
Red Flags Notes that do not mention: Notes that do not indicate: Notes that are almost identical to previousnote(s)––––GoalsAction PlansSuccessesBarriers–––ProgressIf no progress – the reasons for lack of progressPlan to encourage progress
Cindy’s Goal: In three months, Cindy willmake one new friend by improving hersocial skills.– Action Plan 1: Cindy will participate inactivities at her local church, the after schoolart class, and the local poetry club over thenext three months.– Action Plan 2: Cindy will participate in theGirls’ Group once a week for three months.
Incomplete Note ExampleCindy has been participating this month inservices. Cindy’s attendance is consistent andshe talks in groups. Cindy reports that shedoesn’t like the places she’s visited to improveher social skills and she thinks that she mightwant to stop doing that. She feels, “people arerude and don’t want to make friends”. Cindyexpresses concern about attending the girls’group. She likes the group and providingfeedback to her peers but feels like her peers“attack her” when they are providing feedbackabout her reactions to specific events.
How to fix an Incomplete NoteFirst, use your progress note grid toidentify areas that are missing.Review the note for appropriate language.If someone (Cindy, Nancy, co-worker, orauditor) read this, would they understandwhat Nancy is doing with your FRC?
Revised Note with RequiredElementsCindy has been participating this month inservices. Cindy’s attendance is consistent andshe talks in groups. Cindy reports that shedoesn’t like the places she’s visited to improveher social skills and she thinks that she mightwant to stop doing that. She feels, “people arerude and don’t want to make friends”. Cindyexpresses concern about attending the girls’group. She likes the group and providingfeedback to her peers but feels like her peers“attack her” when they are providing feedbackabout her reactions to specific events.
2Debra’s Goal: Improve communication with herson by increasing the number of positiveconversations over the next two months. Debrawill use a journal to log their conversations totrack her efforts.– Action Step 1: Debra will participate in the parentingclass to learn about age and stage, self-care, andcommunication. The class meets for 12 weeks, once aweek.– Action Step 2: Debra will attend the parent supportgroup for the next three months to find support andunderstanding.
Incomplete Note Example 2FA met with Debra at the FRC office. Shesaid she wasn’t doing so good. Shecomplained about her landlord not fixingher hot water heater so we talked aboutways to get her to take action. She is alsovery stressed out because she got a lettersaying that her daughter’s SSI was goingto be reduced because she recently gotfood stamps. FA will look into the SSIissue for her and get back to her.
Revised Note with RequiredElementsFA met with Debra at the FRC office for 30 minutes. Debracontinued to use her log book to review conversations withher son. She has also been consistently attending theparenting class, she just completed class 7. Based on herjournal and feedback, Debra reports that she has improvedher communication skills with her son. She reported having,on average, two more positive conversations each week thanin the past. There was one conversation that she foundparticularly difficult and was able to role play this during themeeting with FA. Debra was able to identify two strategiesthat she had learned through her parenting class as a way tochange the conversation to be more positive. Debra reportsfinding her meetings with the FA to be “helpful” and reportedthat she has “learned a lot”. Debra will continue to logconversations with her son in her journal, attend theparenting classes, and meet weekly with FA to reviewprogress and role play challenging conversations.
Importance of Plan AwarenessBe familiar with plan before session andknow what goals and objectives you planto review with the family/youth.Focusing on the plan reinforces the valueof the plan.
Some Requirements to ConsiderFor each encounter, a progress note mustbe completed.The duration of the encounter must bedocumented.Communications with outsideproviders/resources/referral should also bedocumented
Update Ms. PetersonMs. Peterson met with FA at the FRC office on 3/22/16. Ms. Petersonenrolled in the parenting class and will start next week. She started to trackher conversations with her daughter and is starting to realize there aremore argumentative conversations than calm ones. She is feelingoverwhelmed and frustrated at the situation with her daughter. To add tothe stress, her daughter was suspended again, for threatening a teacher(luckily her daughter was not expelled). As a result they had another majorargument and her daughter ran away for several days.Because of everything going on at home, she hasn’t even looked at the listyou gave her for housing legal aid. She received a letter from her landlordthat she has to sign the lease agreement by next week or they will have toleave by the end of next month (6 weeks). The kitchen sink also broke thisweek and the landlord is refusing to fix it until she signs the lease, whichshe cannot afford (due to the large rent increase).Ms. Peterson cried throughout the meeting. She wants her daughter toconnect with a YA because “nothing else is working”. She needs help now!She asks you to come to the house to talk to her daughter – or at least tryto call her.
Charting to the Goal and ActionPlans: Ms. PetersonGoal: In 4 months, Ms. Peterson will improve communication withher daughter so that angry outbursts will reduce from five times perweek to one time per week. Ms. Peterson will report weekly to theFA to review outcomes.Action Plan 1: Over the next 4 months, Ms. Peterson will tracknumber of calm and angry conversations with her daughter and nothighlights of each. In her routine meetings with her FA, they willreview conversations, identify alternative means to interact withdaughter, and role play particularly challenging conversations.Action Plan 2: Ms. Peterson will graduate from the emotional fitnessparenting class by consistently participating in weekly classes for 12weeks. This course is designed to teach her about her daughter’smental health concerns, improve her communication skills, and gaininsight into her daughter’s developmental stage.
Update: Skyler PetersonSkyler attended her first Youth Group last week. She appeareddistracted and antsy throughout the group. She did not speak withother participants unless she was addressed directly, and on a fewoccasions she was short with other participants. At your meetingafterward, she shared that she feels like she is constantly beingwatched and criticized by her mom and her teachers, and that shefeels the same way in the group environment. This week, Skylershowed up an hour late for Youth Group. Once again, she did notspeak much, but did take notes during the discussion.Reviewing her journal entries, she reported that she has angryoutbursts at school on average of 3-4 times per day. About half ofthese take place with her science teacher, who often singles her outduring class in order to make an example of her.
Charting to the Goal and ActionPlans: Skyler PetersonGoal 1: In three months, Skyler will increase instances of calmresponses to bullying to two times per week, as shown by selfreport to YA.Action Plan 1: For the next three months, Skyler will attend YouthGroup every week for 1.5 hours each week. The group will providean opportunity for Skyler to learn about managing her emotions in agroup setting.Action Plan 2: For the next three months, Skyler will completeweekly journal entries on her successes and challenges withmanaging anger at school, which she will share with YA. Meetings toreview progress and troubleshoot challenges will take place weeklyfor a half hour immediately following each Youth Group.
SMART Goals: – What the person will do, change, or accomplish to achieve Vision – Measurable changes the person will make and skills to be gained Action Plans (in SMART format): – Services and supports that help person achieve Parent/Youth's Vision and SMART Goals – Not li
Intake – R.D. obtains diet history and estimates energy needs. Suboptimal intake is determined as a percentage of estimated need over time. Energy Intake 75% energy intake compared to estimated energy needs for 7 days . Energy Intake 75% energy intake compared to estimated e
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intake tube. 21. Insert the mass air sensor into the K&N intake tube, and use the supplied M4 allen bolts to secure it in place, tightening with a 3mm allen wrench. NOTE: The hole for the mass air sensor is on the opposite side of the K&N intake tube compared to the factory intake tube, so t
Intake Assessment Form Client Name: _ Client Record #: _ Intake Date: _ Complete this form from the client interview and chart review at intake. Sections surrounded by a double border are required. No changes should be made to the Intake Assessment Form. Significant client changes should be recorded on the Reassessment F orm. 1.
