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The Core Function of Reports and Record Keeping

Author: John Herdman, Ph.D., LADC, ICADC/Thursday, December 10, 2009/Categories: Addiction Medicine

As the author of Global Criteria: The 12 Core Functions of the Substance Abuse Counselor- Fifth Edition, I believe in keeping concepts about the core functions simple and easy to understand. You already know the 12 Core Functions. The function of Reports and Record Keeping is involved in all of the other eleven core functions.

For me personally, Reports and Record Keeping has been perhaps the least enjoyable core function to perform. Like most of you, I am a front line counselor and I create reports, write progress notes, correspond with third parties, and read others’ reports. All of this is for client care and program accountability. I’ve been in this field for 35+ years. After being trained by the Air Force as a Drug and Alcohol Abuse Control Officer (a fancy name for a substance abuse counselor), I was stationed at MacDill AFB in Tampa Florida. I recall that we kept client records in a six-section folder. What went into each section was detailed in our Manual of Standard Operating Procedures. Each page was two-hole punched and we. We recorded client information on forms while writing progress notes by hand. Sound familiar? In the a field, most of us still do this. At my agency, Parallels in Lincoln, NE, we’ve improved and now keep our records in a three-ring binder and frequently use word processing assistance to type and print information. Now, the process of Reports and Record Keeping is changing.

President Omaha has stated  “Computerize all health records within five years. The quality of health care for all Americans gets a big boost, and costs decline.” The age of electronic record keeping is upon us. Medical facilities are ahead of substance abuse and mental health facilities with implementing digital processes, but MyCaseRecords Case Management System by Eccentex brings us into this future now.

In November of 2008, I was named Vice-President of the Behavioral Health Division of Eccentex Corporation in Culver City, CA (www.eccentex.com). I offered my agency, Parallels, as a beta site for the development of an electronic case management system called MyCaseRecords. Eccentex recently launched MyCaseRecords (www.mycaserecords.com) and with this the launch, the field of substance abuse counselors comes into the 21st century. This article will describe how electronic record keeping can help substance abuse counselors and facilities to streamline the tasks involved in the core function of Reports and Record Keeping.

What is MyCaseRecords?

“MyCaseRecords Case Management System was especially designed for behavioral health agencies and professionals. It is a full featured, End-to-End Case Management Solution that is affordable and user-friendly use right out of the box. Manage services, cases, paperwork, staff, healthcare providers, claims, billing, plans, authorizations, schedules, and much more in one easy-to-use solution.

MyCaseRecords was designed by behavioral health professionals to address the case management needs of substance abuse treatment services programs”

The power of MyCaseRecords lies in its platform designed by software engineers and behavioral health experts. The system is evolving each week to improve task completion for front-line counselors and the professionals responsible for clinical care and agency operations.

As a counselor, I want a system that saves me time, eliminates redundant data entry, and makes my task of writing reports and keeping records easier.
As a clinical director, I want a system that easily allows me access any client chart anytime, anywhere. I need to ensure that my staff is doing the paperwork in a timely, efficient and effective manner.
As a facility owner, I want a system that provides me reports on my programs; tracks important client variables; improves the processes for program audits, and saves me money.
As a researcher, I see many applications of MyCaseRecords conducting on-going research on variables of interest. MyCaseRecords does all of that.

The paragraphs that follow will explain how an integrated electronic case management system makes all the other eleven core functions easier and relieves some counselor stress of performance in the core function of Reports and Record Keeping.

Screening: Most screening is done on the telephone and the person doing the screening gathers pertinent information about the client. MyCaseRecords gathers this information by having the counselor type demographic information such as the name, address and phone number into an electronic database. One can use the Screening form provided in MyCaseRecords or design one’s own. The pending client can then be scheduled for the next step, Intake, with a specific counselor using the Schedule function.

Intake: At the intake session a person becomes a client. The information already recorded in MyCaseRecords from Screening is available to auto-populate the many forms a facility requires a client to complete in this core function. No more redundant writing of information!  Your agency may still have forms that require a client to handwrite information; however, the goal is to minimize this. The Case Management System has the capability to scan forms such as the signed HIPAA forms and authorizations to obtain or release information into the electronic records and associate the scanned form with the client for easy retrieval when necessary. Documentation of the Intake is often accomplished by a counselor writing a progress note. With MyCaseRecords the Progress Note is documented in an electronic form auto-populated with the pertinent client information.

Orientation: If the core function of Orientation is performed at the same time as the Intake, this can be documented on the same Progress Note as the Intake. If performed at another time, simply document again using the Progress Note in MyCaseRecords. The signed Client’s Rights and Responsibilities form can also be scanned into the client’s electronic record.

Assessment: In my role as Vice-President for Behavioral Health at Eccentex I’ve been involved for the past year in developing a new assessment form. I’ve been honored by having the form named after me – the Herdman Assessment Form or HAF. I’ve used the Addiction Severity Index, the ASI, for many years and have found it necessary to supplement the questions of the ASI with additional questions. I’ve incorporated the information gathered by the ASI and enhanced the process of gathering bio-psycho-social data. I’ve written logic for each possible client answer on the HAF and developed a reader-friendly narrative report. My goal was to not have the narrative sound like it was computer generated, but to have a flow and feel of an individualized report. Although the narrative reports client bio-psycho-social history, the HAF allows the counselor to add additional detail as appropriate for a specific client through an easy word processing function within the HAF. Also, it remains the counselor’s professional responsibility to diagnose, summarize, determine an appropriate level of care (LOC) for the client, and to provide individualized recommendations consistent with all of the data collected in the core function of assessment. The HAF assists in doing a substance abuse assessment; it is not a diagnostic form.

Unique to the HAF is the addition of Supplemental forms or instruments to streamline and enhance the assessment and the report. As an option, if the client took a SASSI-3, the client’s raw scores can be recorded and the HAF automatically calculates the percentile and T-Score. Then the narrative is written identifying any significant or very significant scores on the scales of the SASSI-3.

Some agencies use the University of Rhode Island Change Assessment (URICA) to assess a client’s readiness to change. You have the option of having the client take the URICA on the HAF during your session or have the client complete a traditional paper version and then type the responses into the HAF. The HAF then uses the calculation table available for scoring the URICA and the narrative reports the client’s readiness for change stage.

Many states and insurance companies require the use of the ASAM Patient Placement Criteria (ASAM: PPC-2R) to assist in determining level of care. The HAF provides a Table for the counselor to rate the client in the six dimensions of the ASAM on a 0-4 scale. The counselor remains responsible for rating the client, based upon all the data collected on the client, i.e., from the client interview, collateral information, and assessment tools and finally recommending an appropriate level of care.

The HAF has a Diagnostic Impressions section. The counselor still must make the appropriate diagnosis; however, the HAF with it’s processing power makes it easy to record DSM-IV TR diagnoses without having to memorize codes or spell the full diagnosis.

The HAF has a section called Summary and another called Recommendations. No computer program can write those sections, so a counselor must still write this.

Once the HAF and its optional sections are completed, the counselor clicks the “Generate Narrative” button and the report is ready for proofing and adding any additional comments by the counselor. The HAF saves time and provides a professional and individualized report.

Treatment Planning: Currently, MyCaseRecords has a Treatment Plan Form that allows the counselor to do the client treatment plan. I’ve been asked to incorporate some information from the HAF assessment into the Treatment plan and I am in the process of doing just that.

Counseling: A frequent core function for a counselor is Counseling. Every client counseling session needs to have a progress note completed. Most often progress notes used are for individual and group sessions, but family and other sessions also need to be documented. Using the Scheduling function, once a client is scheduled for an individual or a group session, a “Pending” Activity Form is automatically generated for completion. As an agency owner and Clinical Director, I know how easy it is for a counselor to “forget” to complete required paperwork. I’ve never had a counselor leave my agency without finding out later that a discharge summary or other document was missed. Counselors are human beings and I’m amazed at how much paperwork front-line counselors need to complete. MyCaseRecords makes it easier to document and to avoid missed paperwork that could relate to not getting paid or getting “dinged” during an audit.

Case Management: MyCaseRecords makes it easy to add a note to document the many case management activities for a client. On your home page in the application there is a Dashboard that lists all active clients for a counselor. To the left of the client name is an option to “Add Note”. This is where a telephone call or other case management documentation is recorded. The note then becomes part of the client history available for electronic recall at any time.

Crisis Intervention: It is imperative to document all client crises. Again, use a Progress Note to document the elements of the crisis, steps taken to resolve the crisis and any recommendation plan to change the treatment plan or to take further action.

Client Education: Documenting this core function can be accomplished in a number of ways. The educational topic can be recorded in an individual Progress Note, on a Group Note, or on a Note. Each agency can set procedures for this for all the counselors.

Referral: A counselor can also document the core function of Referral in a number of ways. A letter can be written and scanned into MyCaseRecords; a Progress Note can be prepared; or a Note can be used.

Reports and Record Keeping: The Case Management System allows the counselor to efficiently and effectively complete reports, document client progress and electronically file the reports of others – all organized within a client case for easy access and use.

Consultation: This core function can be recorded on a Note form. At Parallels, I’ve developed an Initial, Intermediate and Discharge staffing form to use with MyCaseRecords. My counselors use these forms to document staffing and consultations for individual clients.

The future of electronic record keeping is now. Medical facilities are ahead of substance abuse and mental health facilities, but MyCaseRecords brings us into this future. I know that the software engineers at Eccentex are dedicated to providing the leading software for substance abuse and mental health counselors and facilities. The platform (AppBase) allows easy changes thus facilitating keeping pace for continuous quality improvement. Eccentex is working on a billing module to complete HICFA forms, individual and third-party billing compatible with accounting programs to avoid double entry, thus saving time and money. I am working on improving the Treatment Planning form and integrating that with the Assessment and with documenting individual and group progress notes. We will continue to enhance the HAF thus giving counselors and agencies additional options to include in client assessment.

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