Treatment DepartmentDocumentation Training Form 253 & Form 54

Annual & Recovery Plan Documentation

Chart Documentation

Form-54Issue Objective Action Step

Form-54 IssuePurpose

• To address and describe barriers for discharge.

• To address and describe short-term goals leading to theresident’s Role Recovery Goal.

Incorporate the following components

• Relevant diagnosis as reflected on Axis in Diagnostic Data

• Drug related legal charges

• Assessment for resident specific drug and alcohol history

• Resident desire to attend scheduled services

• Resident desire to abstain from drug and alcohol use

• Recommended benefit of resident involvement in services

Example Issues

Substance Disorder: Mr. G has a history of Cocaine and Alcohol abuse in the community. He reports using alcohol at the time of his arrest. Alcohol has led to legal consequences, violation of conditional release, and an increase in psychiatric symptoms for Mr. G. Mr. G is referred to Substance Abuse services to obtain skills to maintain sobriety in the community.

Substance Disorder: Mr. K reports use of cocaine, alcohol, and cannabis in the community. He states that drug use has never been problematic for him. Mr. K is seeking Substance Abuse Treatment Services to understand the potential problematic affect of drug abuse with existing mental illness.

Form 54 ObjectivesObjectives should be..

• Simple and Straight-forward• Measurable• Attainable• Realistic• Time-framed• Correlated issue

Objectives require the following components

• Who• What• How• When• Where• Outcome

Form-54 Objective Template

_________ will __________________ by attending ________________as indicated/evidenced by _________________________________ by__________.

Resident’s Name

Increase his knowledgeIdentify skills

Where (Substance Abuse Services)/

When (As Scheduled)

Measurable Component that the person is

indicating progress towards “Increasing

knowledge” or “Identifying Skills”

Date for monitored progress

Example Objectives

Mr. K will increase his knowledge of the correlation between poly-substance use and existing mental illness by attending Substance Abuse Treatment Services as scheduled, as indicated by identifying 3 ways illicit drug use can further complicate symptoms of mental illness by 01/01/2013.

Ms. T will increase her knowledge for avoiding alcohol consumption in the community by attending Substance Abuse Treatment Services as scheduled, as indicated by her ability to identify 5 problematic effects of alcohol consumption on the body and mind by 01/01/2013.

Action Step Purpose

To define and describe the intervention implemented to assist the resident in mediating the determined issue.

ComponentsWhatWhen WhyWhoWhere

Form 54 Action Step Template

Provide __________________ Services, ______________, ________, at _______________, to assist____________ in _____________________________. Provider: ___________________, ____________.

Substance Abuse, Anger Management, Wellness Self- Management

Days scheduled for services (ex. Mon-

Thurs, Wednesdays)

Time of Scheduled

Service (Ex. 1300-1400)

Location (Ex. Bldg. 1051

Rm. 123 Hallway A)

TitleReason for scheduled

services , portion that reflects

congruence with Issue and Objective.

Resident Name

Example Action Step

Provide Wellness Self-Management Groups, Tuesday and Thursday, 1400-1500, at Bldg. 1015 Room 120, to assist Mr. D in identifying and planning goals for his self-wellness to promote recovery and maintain sobriety. Provider: Jane Doe, Rehabilitation Therapist.

Provide Substance Abuse Treatment Services, Monday - Thursday, 10:15-11:15, at Bldg. 1260 room 243, to assist Mr. R in identifying personal advantages of continued sobriety to prevent relapse post discharge. Provider: John Doe, HSC-III.

Congruency

Issue

Objective

Action Step

The issue, objective, and action step should reflect a central theme for the resident’s purpose and benefit in the specified service.

Substance Disorder: Mr. T reports use of cocaine, alcohol, and cannabis in the community. He states that drug use has never been problematic for him. Mr. T is seeking Substance Abuse Treatment Services to understand the potential problematic affect of drug abuse with existing mental illness.

Mr. T will gain knowledge of the correlation between poly-substance use and existing mental illness by attending Substance Abuse Treatment Services as scheduled, as indicated by identifying 3 ways illicit drug use can further complicate symptoms of mental illness by 2/6/2013.Provide Substance Disorder Treatment Services, Monday-Thursday,1400-1450, at Bldg. 1260 Room 315, to assist Mr. T in identifying the complicating effects of drug use on existing mental illness. Provider: _____________ ,RT.

Form 253Issue Objective Monthly Progress

Form 253 Components

Objective

Issue

Role Recovery Goal

Progress towards Objective

Form 253 ComponentsDescribe

Services/Activities Provided

Next Steps/Revised Objective/Explanation

for change

Annual Assessment Information/S.N.A.P.s/ Recommendations for

ongoing services

Component: Progress Towards Objective

What to include•Resident quotations that reflect the specified measures captured in the resident’s objective

•Resident progress in understanding material associated with the objective

•Supportive detail as to how the resident has made progress towards specific objective

•Lack of progress towards objective with explanation as of why—ex. attendance, participation, attitude towards services

•The resident’s perspective of their individual progress in services in quotations.

•The resident’s satisfaction with services as expressed by the individual in quotations.

What is Progress? • Attendance does not automatically equate to

progress made

• According to FSHOP 151 – 3 the objective shall be changed when progress has been achieved (goal or objective met requiring a new goal or objective) or a lack of progress towards meeting an objective for two 30-day review periods.

• 253 progress note does not differentiate between levels of progress; it’s a polar yes or no.

• Progress is solely based on the resident’s current objective

• It is the responsibility of the practitioner to provide residents with an opportunity to make progress

– practitioners will ensure resident knows current objective– practitioners will develop appropriate S.M.A.R.T.

objectives– practitioners will be proactive e.g. – e-mail recovery

team members of residents absence from treatment, visit resident on ward.

• If a resident completes any portion of their objective during a 30 day review period it is considered progress

Component: Describe Services & Activities

What to include

Description of group activities, subject material, and themes discussed in groups for the documenting period

Indicate and briefly describe the specific activities the resident participated in for the documenting period-- impact, outcome, resident opinion

Visits on the unit is providing services and should be captured in this portion of the 253.

Address behavior: •That which could compromise resident progress in services and that of others in the scheduled group. •That which the service team needs to address aside from contacting them throughout the month•Incidents observed while in services

Component: Next Steps

What to include

• any necessary changes and adjustments to the resident’s current objective. • resident’s newly established objective• how far resident is with current objective• if motivation is necessary to strengthen resident attendance • detail of resident attendance --ex. For documenting period resident absences are due to 4 refusals, 2 Unit Appointments. • if no changes are needed at this time and resident chooses to continue with objective, indicate this.

Component: Assessment Information

By completing form 253 we want to indicate our best understanding of residents’ needs and progress in our services. The provider must include all available assessment information for the documented resident with brief description of what the assessment score means.

Ex. What does a score of 7 on assessments mean?

Mr. T scored a 7 on the DAST with a score over 12 indicating “problematic drug use.” and a 7 on the MAST with results over a 5 indicating “problematic drinking.” Both scores reflect a history of problematic use without formal consequences identified. As mentioned above Mr. T’s URICA score resulted in a 6.43 signifying very little motivation for treatment. The low score is likely attributed to the resident not acknowledging a previously existing problem as indicated during assessment and interviewing.

Recommendations: Determining Needed Services

Determining resident’s need for services is based on the following criteria:

1. Assessment results

2. Health, safety, and security factors

3. Mandated Florida State Hospital Operating Procedures

4. Person’s served perspective of needs and desires

5. Drug related diagnosis

6. Social, legal, or other identified areas negatively impacted

S.N.A.P.sSTRENGTHS: assets, resources and natural positives:• Insights from childhood and past experiences• Understanding of others• Information seeking• Forgiveness• Humor• Working with the cultural stereotype• Spirituality• Connecting with others

NEEDS: liabilities and what the person needs for recovery and wellness:

• Any treatment or rehabilitation issue

ABILITIES: (interests) skills, aptitudes, capabilities, talents and competencies:

• Self-Care• Reading• Writing• Playing a musical instrument• Using a computer

PREFERENCES: those things the person served feel will enhance his or her treatment experience:

• Any Enrichment issue• Group Interactions• Individual interactions• Learning Style

Example Documentation

Avoiding opinionated statements Content should be formal, factual, and objective.

It is important to ensure information captured on documentation is specific to that individual while maintaining an objective tone.

This involves avoid certain statements and content.

Because we do not assess an individuals knowledge it is not appropriate to say “the resident lacks knowledge.”

Other statements and words to avoid:

• “the resident acts out”• “the resident is/is not problematic” • “Uncooperative”• “Manipulative”• “Normal”• “Functional”

Avoid labels, personal judgments, opinionated statements, value-laden language, (personal opinion rather than professional opinion

Record observations that allow the reader to draw their own conclusions

Self Auditing Upcoming expectations now include 100% compliance for Form-253 documentation audit.

Be sure to audit your documentation for the following essentials:

• Compliance with 30 day documenting period

• Avoid generic non-specific issues

• Ensure that the objective created is unique to the residents needs

• Do measures indicate progress towards specified objective

RP and Annual Documentation Documentation for Recovery Plan Meetings and Annual Meetings involve similar components with the major difference involving the resident’s progress for the length of time being discussed in the documentation.

Recovery Plan: Progress discussed over previous 6 months or since the resident’s start of services (should the amount of time in services be less than 6 months).

Annual Note: Progress for past year or since the resident’s start of scheduled services (should the amount of time in services be less than 1 year).

Components

• Progress summary of progress made towards objective(s)• Resident’s perspective of progress for the documenting period (RP: 6

months, Annual: 1 year)• Resident feedback regarding services• Information regarding recovery plan• New objective proposed• Resident desire to continue with scheduled services• Resident level of satisfaction with scheduled services • Date and location of provider’s meeting with resident clearly indicated• RP Team Meeting indicated

Chart Documentation

Chart Documentation Purpose

To provide a chronological representation of the resident’s course of treatment during hospitalization.

To document resident goal progression/regression and achievement.

To provide a legally credible document of resident activities and contact during hospitalization.

To document all treatment and services provided to the resident, including response to and outcome of treatment.

When documenting in a resident’s chart..•Make progress note a clear concise observation or description of an event.

•Ensure the entry is entered directly after interaction or observation unless prevented by unusual circumstances.

•Ensure the progress note is in the chart at all times to maintain chronological order of documentation

•Use black ink only, ball-point pen preferably.

•Date each entry with the month, date, and year

Chart Documentation (Cont.)

• Time each entry using sidereal time with the approximate time of entry

• State the issue number or letter

• Write legibly and use print

• Sign and indicate your title

While documenting in resident charts be sure to avoid..

• Skipping lines• Leaving blank spaces • Judgmental tone• Subjective interpretations• Marking through errors• Writing over an entry• use of white-out for corrections • Using another resident’s name (instead, use the resident’s #)• Making an entry and/or signing for someone else