Documentation

One of the most important things about this field is documentation. It's extremely important to document any incident that happens and what kind of intervention was used. When one is working with the mentally ill it is important to document their behavior so you can track their improvement. If one resident is admitted to the facility and he has trouble with threats, every time this resident threatens others it needs to be documented. When a therapist is looking back at his chart, she may see that he went from using twenty-seven verbal threats one month to ten threats the next month. That shows progress. For obvious reasons one must do correct documentation of behavior and interventions.

Now, when you look deeper into documentation it becomes more complicated than just documenting different kinds of behavior. Most facilities such as mine have several residents that are supported by Medicaid. In order for the facility to be paid my Medicaid they must comply with Medicaid documentation standards. There are so many complications with this. At times the standards change and it is not accurately communicated to the MHCs and therapists doing the documentation. Sometimes the standards have always been there but for some reason the facility either did not know/understand the standards or they just did not comply with them. Noncompliance leads back to paybacks to Medicaid from the facility because Medicaid will not pay if documentation is non-compliant. There are specific things that Medicaid is looking for.

For instance, only certain abbreviations can be used in documentation: "Q" for "every", "@" for "at", and "&" for "and". You cannot use "min" for "minutes" or "cont" for "continued," which are both common abbreviations that my facility used on a daily basis, until we discovered we were not getting paid by Medicaid for those residents whose documentation was not correct. Furthermore, there are common errors made in documentation that are difficult to distinguish the difference at times. When continuing a narrative note on the back of the page, you must continue it in a very specific way.

INCORRECT CORRECT
(continued) MY NAME, MHC MY NAME, MHC (continued)

When correcting errors you must put one line crossed through the error and initial it.

INCORRECT CORRECT

All documentation must be in the BIRP format, and must be child specific. BIRP stands for Behavior, Intervention, Response, and Plan. When documenting behavior, one cannot simply say that the resident "followed all staff direction, earned all his points, controlled his anger, and participated in all groups,." It must be more specific than that, even if that statement is true for that particular resident. A better statement would be, "Robert appears to be working toward his treatment goals of 'controlling anger.' He was able to express his anger appropriately by talking to staff and his peers and stating his feelings without yelling or throwing objects." Intervention documents anything that staff did for the resident to help them. This does not have to be as detailed as the behavior and response. An intervention might be, "Staff talked to Robert about why he was angry and encouraged him to express his feelings in a healthy way." Typically staff have difficulty with response. In the past a common response was simply, "Robert is currently in his room." A response should not be a place to document the resident's location. It should be a detailed explanation as to how the resident responded to staff intervention, "Robert talked to staff and said, 'I'm mad because Nathan took my CD without asking and he scratched it.'" The plan is probably the most simple out of the BIRP format. Plan describes what staff will do next for the resident, "Will continue to monitor Robert Q15 minutes." - remember, "Q" means "every." There are times when the plan needs to be more detailed. When writing out the plan one must take into consideration "special precautions," which is something I will go into more detail to in another entry. Special precautions represent a different kind of monitoring. For example, "close observation" means that the staff must keep special observation on the resident. This is often times conducted when the resident is a threat to self or others. In that case, a correct plan would entail, "Will continue to monitor under close observation." If a resident is under special precautions and it is not mentioned in the plan, it's considered deficient paperwork.

There are even specific times to which staff should begin writing documentation narratives. If one writes a narrative and it is before the acceptable time to write narratives, it is unacceptable. Furthermore, if you write one documentation narrative and something happens after you wrote it, you must write another narrative documenting that new event.

When documenting groups therapy sessions, it is unacceptable to simply mention that the resident "actively participated," which is another common mistake that my facility made. You must give examples as to how the resident participated and acted in group. This way there is support to back up any evaluations you made on the resident. If you think they participated sufficiently, describe what they did. If a resident refuses to participate in group, document what they were doing instead and where they were. If you simply say, "resident refused" or "did not participate" there are not enough details to determine if this group intervention can count toward the required number of groups per week as required by Medicaid. Furthermore, a certain amount of residents need to be in group in order for it to count as a group intervention. If one documents group as having "one participant" it will not count as a valid group. Because it is required to document the location of every resident every fifteen minutes, group notes and monitoring should match. It would not be acceptable if a group note documented group taking place from 1800-1830, but the monitoring says that Robert was in his room at 1800, in the hall at 1815, and with his therapist at 1830.

There are many miscommunications as to what exactly is correct documentation. There is a very large problem with what Medicaid considers "child specific" narratives. It appears that there is no clear explanation as to how detailed a narrative has to be. Should staff document how many times a resident turns in their sleep? Should staff document how often residents speak to one another? We keep tally marks as to how many times they curse, but should we document exactly which curse words they are using? At times, although it sounds ridiculous, it appears that Medicaid requires staff to document how much time they spend in the restroom.

I mentioned a few things in this entry that I plan on elaborating more on later. This includes groups and special precautions. I will explore these topics next.