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The Golden Thread of Documentation

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Lindsay Johnson

on 17 August 2017

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Transcript of The Golden Thread of Documentation

1. Each piece of documentation must flow logically from one to another so that a reviewer can see the connection.
The Golden Thread of Documentation
to the Treatment Plan
to Documentation
Treatment Plans

1. The treatment plan is an agreement with the client that outlines the course of treatment and expected achievements.
*Remember the golden thread.
The Plan must address the problems/needs identified in the assessment.
The plan must also relate to the services the client will be receiving.
Objectives should be SMART-
1.Simple or Straightforward
2. Measurable
3. Attainable
4. Realistic
5. Time- framed
2. The assessment must be coherent, cohesive and establish medical necessity, and must identify symptoms &behaviors to be addressed in the treatment plan.

3. The treatment plan structures treatment to accomplish identified goals/objectives using specific interventions.

4. Progress notes must flow from the treatment plan and document both the service provided and the client response to the interventions.

5. The notes then lead to the treatment plan review/update.

6. The cycle continues until discharge.
It is Golden!

If accurately followed, documentation will support each decision, intervention, and note- It contributes to a complete record of client care that is error free and ready for reimbursement!
Objective Example :
Dinny will master two stress reduction skills within the next 60 days as measured by self-report of successfully resolving conflicts/problems without self-defeating behavior.
Staff will meet with Dinny every week in the community to practice stress reduction skills for two months.
Staff will provide skills training on stress management one hour per week for 60 days.
Documentation: Common Errors
1. Missing the staffs intervention- Notes describe play by play of what the client did but not what the staff did.
2. Missing progress toward objectives.
3. Notes contraindicate medical necessity.
4. Canned language and plans- All language (excluding group descriptions) must be unique and not cloned. Plans need to be related to achieving the objectives not attending next service.
Moving Forward:
Review the
Golden Thread
with staff and ensure they are aware of what we are looking for in documentation.
Document all review of notes with staff.
Contact Lindsay- 602-599-5637 or Tom 602-599-5415 for any assistance!
Full transcript