Treatment Planning and ReAssessment to Enhance Mental Health

Foreign. I'd like to welcome everybody to today's presentation on treatment planning and reassessment. I AM your host, Dr. Donnelly Snipes. Today we're going to review multiple ways of writing treatment plans, including using the integrative summary, FARs, CANS, ASAM and LOCUS. And if you're not familiar with all of those different instruments, don't worry about it because your locale probably uses one of them or something slightly different. We're really just going to be talking about how to use some relatively standardized instruments in order to help guide treatment planning. And the reason I'm doing this is, you know, if you are a clinician and you have interns that are working with you, I often, very often had interns working with me when I was at Meridian and a lot of them had never written a training treatment plan and had no idea where to start. And even some of my staff really struggled with figuring out how to write a treatment plan and wrapping their head around it. And it's really relatively simple. Another challenge that people face is not being able to write effective ones and the time crunch. You know, we all have a desire to work with people, but not so much of a desire to actually do the paperwork. We're going to continue and review the purposes of the reassessment and best practices for documentation and finally finish up with time effective methods for completing treatment plans and reassessments. So let's start out talking about the integrated summary and reassessment. The integrated summary is one tool that you can use and if you remember, you may call it the comprehensive summary in your clinic. It goes by various names, but ultimately the integrated summary summarizes the person's story. It's sort of the executive summary for the entire assessment to enhance communication between providers. It synthesizes information to support the diagnosis and level of care. It grinds my gears when I read an integrative summary that is just a recapitulation of the assessment. There's nothing integrated. Nobody's connecting the dots. It just starts all over again, basically telling me the exact same thing. And the integrated summary can be used to drive treatment planning by identifying what the problems are you're going to talk about. For example, Sally smith is a 35 year old cisgender white female female who is presenting with symptoms of depression as evidenced by fatigue, apathy, in, in increased guilt. You know, you see where we're going here. So you're going to define anytime you say the person has a diagnosis or the person has a problem, you're going to have to define. How do I know this? You. You're going to, in the integrated summary, identify how these problems are impacting the patient. And then you're going to talk about, okay, so we have these problems as evidenced by they're impacting the patient in these different ways. Now this is what we're going to do to try to address it. So again, it's an executive summary that kind of squishes everything together in a short form. Form. So if someone is short on time, which I hope that's not the case if you're taking on a new client, but they can scan the integrated summary, the comprehensive, comprehensive summary, in order to get a understanding of kind of where that client is, you're going to do the same thing. Let me go back. You're going to do the same thing with the reassessment. The reassessment is exactly what it sounds like. It's just a, an abbreviated version of what you did at the primary assessment. Why? Because you want to see the progress the person's made. Any changes that have happened in their life, for example, in substance abuse treatment, for example, and a lot of other different presenting issues. When the identified patient seems to start getting better, that is great. We see changes in the person's thinking, their behaviors, all these kinds of things, but those changes may cause conflict in their family of origin. So, you know, that might be a new issue that creeps up as they make a change. Because, remember, for every action, there is a reaction. Not necessarily equal and opposite when we're talking about psychology, but we do want to frequently reassess in order to make sure that we are aware of new obstacles, new hurdles, new challenges, or new strengths and new resources that may be presenting for this person. The integrated summary and reassessment both have a summary of the presenting problem or problems and, and evidence of impairments, the person's diagnoses, you know, as you give them, because, you know, most of our clients are on insurance. So we're going to have to use that and the evidence to support that. If you are going to your Blue Cross or Blue Shield or Aetna or somebody and trying to get additional authorization, additional sessions authorized, you're going to need to be able to demonstrate what's going on with this person. And if you've done insurance billing, you know, this is old hat to you. If you're working in a community mental health center. Until I went out into private practice, I was very isolated from this. I didn't really realize the importance of supporting my diagnosis with the. As evidenced by. And it's. It is really important. But that also helps the client understand, you know, what these symptoms are and kind of what depression is or anxiety or whatever their presenting issue is. You also want to have recommendations for treatment and defense using some sort of standardized assessment instrument. And we're going to talk about why this can be very useful. Do you have to do it? No. But is it generally a best practice? Yes. Most states, locales, insurance companies require that you use some form of a standardized patient placement tool or assessment instrument. Depending on. They're called different things. The current focus of treatment and how the person's current strengths and needs will be used is also part of the integrated summary as well as the reassessment. What are we going to address? You know, when you start out, what am I going to address in the first week, in the first month during the reassessment, you know, you're looking at it going, okay, we knocked off, we, we checked off all of these goals or objectives here. What are we going to work on for the next week, month, maybe even quarter? I really, I, I strongly urge you to do treatment plan reassessments at the very least, if not sort of semi comprehensive reassessments, at least on a monthly basis. You're going to talk about why each issue will be addressed, how it will be addressed, and family involvement, if any. It's also important each time you do the integrated summary or the initial assessment and the reassessment to make sure that there is some sort of relapse prevention plan. And this is true for any presenting issue. Remember, relapse just means a return to a former state of being. It doesn't necessarily mean addiction. We want to make sure that people have some sort of plan to bridge the gap between sessions. Writing good integrated summaries and reassessments is really important because they are where you get to summarize the facts, state and support your somewhat subjective opinions. If I say, yeah, I think this person is done depressed, well, that is somewhat subjective. And what I mean by that is when I see someone and I think they meet the clinical criteria and are experiencing clinically significant distress, you know, there is no hard and fast rule for that. So there is a little bit of subjectivity and diagnosis, but this is where I get to support it. I get to support why I'm diagnosing somebody. For example, with bipolar 2 instead, instead of unipolar depression, you're going to support your diagnosis and support your recommendations for treatment. Why are we doing this? And this is important not only for insurers, but also for the client. The, the patient. The client, whatever you call them, where you're at, needs to understand what's the purpose. Why am I doing this? If you're asking them to go to the phys, go to the doctor and get a physical. Why is that? Well, because we want to rule out anything like hypothyroid, hyperthyroid, hormonal imbalances or anything else that might be physiological that's contributing to their symptoms. And again, it's where you develop and state the basic or preliminary relapse prevention plan. And this is something that's going to be evolving over the course of treatment. But I really want people to focus even in that first meeting. What is it that I can start doing today in order to help myself start moving forward? Most people can look back over what they did today, yesterday, over the past week that might be contributing to their current condition. You know, sleeping too much drink, drinking too much, hanging out with stressful people, burning the candle at both ends, whatever it is. A lot of most people can identify something that they know is not that they're, they know they're doing that's not in their best interest and they can say, I can start doing this. I generally with my clients also give them a handout of some of the basic, you know, top 15 things you can do in order to start moving toward health and happiness. And they can choose from that. They don't have to do all of them. They don't have to do any of them if they, if they don't want, but it starts giving them things to think about. The integrated summaries and reassessments should be a quick read. You want somebody to be able to go in there if an auditor comes in or the physician that you're working with comes in because, you know, they only see their psychiatrist or physician, you know, quarterly or something. They can just read those really quick and have a really good handle on where this person is at and any obstacles, hurdles, challenges or resources that may need to be considered. The integrated summary and the reassessment. Remember I said, you know, if you're working with insurance companies and you're trying to authorize additional sessions, if you are in community mental health and it's state funded, you may be trying to defend or advocate whatever word you want to use for your clients. Staying longer. We the program that I worked in for a long time was a 30 day residential treatment program. Very rarely did people actually leave in 30 days and it was up to the clinician to articulate why this person may need to stay on for an extra week. And we reassessed every week. But it was really important for them to be able to articulate that. And if they weren't doing these frequent reassessments with the client, they may not have the ammunition or the data. It's better than ammunition to support why this person should be allowed to stay for an additional week. And the integrated summary and reassessment also supports how we, as clinicians, as treatment centers, as communities are going to assist the person in a meaningful way in improving their emotional, behavioral, social and physical functioning. And when I say in the community, your treatment plans and your integrated summaries and reassessments are also going to include referrals, whether it's to social services, whether it's to a hud, whether it's to, you know, some sort of. To a physician. Whatever it is, it's going to include a multidisciplinary swath of supports and services that can help the person start feeling better. To figure out if you have done a good integrated summary or reassessment, read it like a reviewer. What's wrong? How is it impacting the person socially, emotionally, physically, occupationally? What is maintaining this behavior? What do we need to address? What strengths and supports are already there and how can they be used? What level of care is recommended at this time? Remember, reassessments occur periodically throughout treatment. Why is this level of care needed? And what are the goals for this level of care? If I am saying that somebody is, you know, ready to discharge from residential but needs to step down to intensive outpatient? Okay, well, what are the goals for. For iop, and how will we know when they're ready to step down to tr to traditional outpatient? And how can we help the patient avoid a higher level of care which kind of goes into. Why is whatever level of care you're recommending, why is it needed? When I work with interns, I give them a rubric so they can score their own documentation before they turn it in. And this is it. What brought the patient to treatment? All of these things should be addressed in the integrated summary and in each reassessment. And the score on the right hand side is the weight of that. If it's a plus two, that's one of those things that is more important. So what brought the patient to treatment? What information do you have from referral sources? Family members, and I use the term family really generally about the problem. If families involved in treatment if they're involved in the recovery process, then at the reassessment, we also want to get their input on what's changing for the better, what might be a problem, a brief history of the problem and efforts to deal with it. And in the initial assessment, you're going to talk about, you know, what they've done up until coming to treatment. In the reassessment, you're going to talk about what they've done in the past, you know, month or three months since they started treatment, you know, what efforts have they made to deal with it, what's been successful, what hasn't. So it's an ongoing narrative. Diagnostic criteria supported in the integrated summary with want to make sure that we're still looking over that. If the person was diagnosed with major depressive disorder at the intake and they have gone into partial remission, then we want to make sure that we do. Note that in the reassessment level of care dimensions addressed, supporting our recommendations. We're going to look at several different instruments in a few minutes, which is kind of why I'm rushing through this part, because there's a lot to go through. But depending on what instrument you use, whether it's the CANS or the FARS or the locus or the asam, you're going to have a little bit of a different twist in this area. But you do want to, in this area, describe why you are recommending this level of care and how it's supposed to help them. The treatment plan is developed and reviewed and includes family involvement and addresses current biopsychosocial needs. And what we really want to look for with family involvement is those people that are important in that person's life. They don't have to be blood relatives. They can be whoever that person defines as their social support. The treatment plan incorporates client strengths and available supports which are ever evolving. Relapse prevention plans. Describe are available and describe what's going to be done to bridge the gap between sessions. And both the initial integrated summary and the reassessments Identify referrals to identify providers with due dates as needed. You know, as I said, as people start to progress through their recovery journey, they may need different referrals. You know, you may start out with counseling and, you know, referral to a physician to rule out physical, physical health issues and maybe consider a short course of psychotropics or something, yada yada. Then you go to the first reassessment. The person's doing really well, they're making a lot of progress, but they've got some trauma issues that are emerging now and you feel like they've got the, the strengths and the skills in order to be able to, you know, start approaching some of those trauma issues. So maybe you make a referral to an EMDR provider. Pitfalls in writing effective treatment plans and doing these integrated summaries and reassessments. The first one is failing to use objective, measurable goals, as evidenced by we want to know, you know, we want to be able to answer the question, how will I know when this person has met their goal? And the person needs to be able to answer the question, how will I know when I've met this goal, when I am not depressed anymore, you know, what's that going to look like? And generally it looks like a improvement in one or more symptoms. So we want to be able to make sure that we break it down a little bit granularly. Because if you say, you know, the person comes into treatment and, and their, their goal is to, you know, not be depressed anymore, that could be six months down the line. And it's really hard to stay motivated for six months. So we really want to look at what are our goals for this week, what are our goals for next week, what are our overarching goals for this month? So people have incremental steps and they can see the gradual progress they're making. Another issue we have is not getting client feedback and buy in. And this is so important. And I know it seems like, oh my gosh, you know, where am I going to find the time to do all this? But we'll talk about how to do that in a minute. In most organizations, you can really make it work as part of the treatment process. But if the client is not participating in the assessment and treatment planning process, if we are doing it to them, if we are doing it for them, that is not empowering. When we encourage the client to become involved in their own assessment and really talk about issues instead of just interrogating them, we, you know, put things out there and we say, let's talk about this. You know, if you think it's a problem, tell me why. When we start talking about treatment planning goals, having them identify what their goals are and which ones they're most ready to change, then it becomes more about them making progress towards their recovery, towards their health and happiness, and us being facilitators in the process, instead of us taking that superior treatment role where we're doing something to them, I want to empower them to, you know, take their health and happiness by the Reins. Another pitfall is failing to ask why the client might lose motivation for change. A lot of times we assume everybody is gung ho and they're going to just keep going gung ho. And we really need to ask ourselves, if the person starts waning in their motivation, we need to ask ourselves, why? What is that behavior saying? Why is this process not as rewarding anymore? And what can we do to enhance that motivation? Which brings us to failure to reassess frequently enough and make sure that the person has sufficient rewards. And I know that sounds silly or may sound trite, but it is important. Just think about anytime you've tried to change your own behavior, whether you've tried to stop smoking or start exercising, whatever it is, we need that periodic reinforcement. Not just knowing that, hey, you know, I'm doing something good for myself, but we need to be able to get that dopamine rush. Let's be frank, because dopamine is that neurochemical that says we can keep doing this. You need to keep persevering in this task. So we need that dopamine. What is going to help us with that? Treatment planning sets measurable and achievable targets, defines the whys of our interventions, and increases client efficacy. Their, their self confidence that they can do it through accomplishment. Every little step. You know, think about when your, your child or your grandchild was, was trying to learn how to walk. You know, the first thing they did. Well, back up. The first thing they did was learn how to roll over. And it was like, oh, yay, they rolled over. And then they learned how to get up on all fours and rock back and forth. And then they started maybe belly crawling. You know, there was a progress. We didn't wait until they could walk before we said, yay, you're mobile. Every little step in the process was a magnificent accomplishment. We also want to make sure there's frequent reassessment to help the person identify their own progress. You know, sometimes it's hard to notice day to day how you're doing, but if you look back over your journals or your logs or, you know, you do a weekly reassessment, you can say, you know what, I actually did make some progress this week. You know, good for me. But it also allows us the opportunity to identify hurdles. A lot of people were in treatment before COVID happened, and their treatment plans hopefully changed once people started being, you know, locked down. Quarantine. There was panic, there was all this stuff, because guess what? Whatever was super important back in February may have lost a Little bit of its primary importance during this current crisis. You know, things happen, life happens. You know, life doesn't just go on pause while you're in treatment. So it's important for us to be able to help people reassess and go, okay, I was, I'm making really good progress on this issue. However, maybe I need to push pause on this for a minute because I have this other bigger issue that is really weighing on me and distracting me from being able to focus on. And it also allows us to identify waning motivation. If somebody comes in to do their treatment plan reassessment and they're hemming and hawing and they really haven't made much progress that week as, or as much as is expected, we can talk about it right then. Instead of waiting for a month or three months down the road and going, well, why haven't you been doing what you were supposed to do? Which provides us opportunities for rapid cycles cycle change. And rapid cycle change means making small adjustments, but only one small adjustment at a time to see how that affects the bigger system and then reassessing in a short time frame, like a week. And if that's going well, then maybe making another small adjustment to help the person move forward instead of trying to change everything all at once or which would require, you know, maybe three or six months to figure out what's going on. So how do we do this in a time effective manner? Get the client's assistance, get the person's participation and buy in. And there are four parts to this. The way that I do it at assessment, I provide people with a treatment planning worksheet and they're going to take this home with them. I don't do treatment planning on the same day that I do the assessment because the assessment just takes too long and people are usually ready, you know, kind of brain fried by the end of the hour. So part one, what I have them do is identify what is important in their rich and meaningful life. What people, things, activities. We talk about what this is going to look like, what I'm hoping they're going to be able to bring back to me the next week. And also of those things that are important, which of those things do I currently have in my life? Well, hey, you know, sometimes a lot of times we're so focused on what we don't have, or I can be happy when I finally get that we forget the things that are important that we currently have in our life. So this is one little step to helping people identify what resources, strengths, tools and important Things they currently have. Part two, what problems am I currently having? And this is where it's really important for the client to start self assessing and figuring out, okay, where might these issues be coming from? You can do something that's kind of free form like the PACER dimensions, the physical, affective, cognitive, environmental and relational dimensions and give them a worksheet. There's I don't have much better, much of a better word. And each on the worksheet I list each one of these things on its own line. Health, nutrition, sleep, energy, medication, pain, other and then under Affect, depression, anxiety, guilt, grief, anger, mania, happiness, other. Anyway, it's kind of a lengthy sheet but it gives them an opportunity to go through each thing one by one and identify any issues they may be having. Because sometimes people kind of gloss over a lot of stuff when they think, okay, this is a mental health issue and they get too focused on the cognitive or too focused on the relationship or whatever and they miss the big picture. The goal is to help them see the big picture picture. So let's talk about a couple other big pictures. If I can get these to open, hopefully I can. Woohoo. The Functional Assessment Rating Scale. This is one of my favorite. It comes out of the University of South Florida. It's available free online and this is the manual that teaches you how to use it. But we're going to skip over that for brevity. The FARs or Functional Assessment Rating Scale. I love using this one because it identifies multiple different problems like depression, anxiety, hyper affect, thought process, cognitive performance. And then under each one it identifies symptoms of that issue. So that whole as evidenced by piece is right here. So the person takes it and they say, yeah, I feel like I've been depressed, I, I've had depressed mood, I felt worthless, hopeless, lonely and had sleep problems. Okay, that gives me a lot of stuff to work with. So we can start addressing each one of those maybe one at a time. So that's the fars. And when I do reassessments, I have them do this again for themselves again. And we talk about, for each one, you know, progress that they've made. And a lot of times they will see progress. For example, in depression, they may notice that they haven't been depressed as much. Maybe they rated it as a seven when they first came in because their depression was just, it was really bad. And when you do the reassessment a month later, maybe we've moved down to a five or a six. They, they're sleeping better, they're, they feel Less hopeless and maybe they feel less worthless doesn't mean it's gone completely. But encouraging them to look at each one of those dimensions that they identified as a problem and figure out, am I the same as I was a week ago or a month ago, or am I feeling better now? For re full reassessments, I only do those once a month. Depending on your agency, you may only do them once a quarter. I really strongly suggest once a month in order to get the most bang for your buck, so to speak. But so once a month I would give people the fars again and allow them to complete it. And then we would talk about why they scored themselves the way they scored themselves. So that. That's one of them. Now, the cans I have not personally used, but it is one that is very popular now among a lot of different agencies. And we'll scroll down here. There's a lot of stuff beforehand, but I'm just going to scroll down to pages six through eight and you can look at these in your classroom. I know the type is really small right now, but I just kind of want to want you to see what we're talking about in the cans. Instead of breaking it down through, you know, depression, hyper affect, yada, yada, like the fars just did, it breaks it down early childhood, transitional age, youth. And then it talks about different issues in each place. Their family difficulties, developmental needs, sexuality, trauma issues, substance use, violence. So the cans really does look, and it's designed to be trauma focused. And obviously the C stands for child. So this one is for use on obviously people under the age of 18. But it does give you a lot of different areas to identify that the person may be struggling with or that may be contributing to their current issues. The Locusts is another popular one with a lot of insurance companies. And we will go down to page 108. Maybe. I do like the Locust, but it takes a while to do so you may not feel like you've got that kind of time. And the, the Locus really looks at their risk of harm, their recovery environment. So if they say they have a limited support in their environment, we're going to talk about what that looks like and why that is the functional status. And with the locus, I tend to do this with the client instead of sending it home with them because until they get used to the definitions, it can be kind of cumbersome. Treatment and recovery history, comorbidity, engagement and their recovery environment. And finally, y' all know my favorite the asam. The asam is. A Very quick and easy measure to use. It measures people's needs for treatment in six different dimensions. They're acute intoxication or withdrawal potential. Obviously, if you're dealing with somebody who has substance use issues, biomedical conditions and complications that can include everything from cirrhosis to chronic pain to diabetes. Anything that might be complicating the picture, emotional, behavioral or cognitive conditions and complications, readiness for change, relapse or continued problem potential and the supportiveness of their recovery and living environment. This one is probably the most broad. Well, this one and the locust are relatively broad. And so I tend to do both of these with the client instead of sending them home with some sort of a check sheet. If you're going to do a check sheet and send it home with the client, you know, I really like the fars or a self made like, like the pacer self assessment that encourages the person to really look at different things and think about different aspects of their physical health, their relationships, their environment, etc. That may be contributing to their problem or where they may have some strengths. So part three, you know, part one was what does a rich and meaningful look like, life look like and what do I have currently? Part two is going through some sort of standardized assessment to try to identify presenting issues, biopsychosocial issues, needs and strengths. Part three, based on doing that standardized assessment, what changes? And this is the client asking it, what changes do I need to make? And rank them in order to most. From most to least ready to change doesn't mean it's most to least important. It's most to least ready to change. So if somebody knows they've got issues in their family of origin, there's a lot of conflict, but they're not quite ready to go there yet. They are more ready to focus on improving their sleep. Okay, that's fine. Any positive change and this is that ripe rapid cycle change thing. Any positive change in the system is probably going to have reverberating positive issues. So I want to know what are you most ready to change? Whatever you're most ready to change. If we start working on that, that's going to start that momentum and we're really going to start off on a good foot because they've got their motivation, they're ready to do it. Part four, for each problem identified, when have the person ask answer the questions. When I do not have this problem, what is different and what can I start doing to address this issue? Now I know a lot of this has been kind of vague, so let's put it all together, for example, and. And you want to do this with the client. This is what we do in my treatment planning sessions. We go over that checklist, the FARS or the pacer, to identify what they think their current presenting issues are or things that are contributing to their current presenting issues. They rank them in order of readiness to change, and then we go through each one. You know, usually I start out with the top three, because if they've identified 15, you could be there all day. Start out with the top three. So this person identified fatigue as one of the issues that they are most ready to address. What will be different when my problem is resolved? I will be less fatigued as evidenced by not needing as much caffeine, feeling rested. When I awaken in the morning and be able to stay up for 14 to 16 hours each day, that means they're getting anywhere from 10 to 8 hours of sleep. And that's about right. If they're not able to stay up for that long, then they're still probably struggling. So that gives us something pretty objective. Okay, so that was. Is the statement. And then we go down and I ask them, okay, what are you going to do to start addressing this? And when I work with clients, I have them start out by learning about the issue in general. So in this case, learn about the causes of fatigue in general. What, what could be causing your fatigue? And I give them handouts, I give them resources. I don't make them go on PubMed and try to figure out, figure it out for themselves. The next objective, identify which of those things is causing my fatigue. You know, maybe the person has relatively good sleep hygiene. So making sure that, you know, they're turning out the lights and, and stopping blue light 2, 2 hours before bed isn't an issue for them that's not contributing to their fatigue. Okay, well, no issue, no sense addressing that. So what is it that's contributing to that person's fatigue? Develop a plan for addressing each thing that's causing my fatigue and then start changing one thing each week that is contributing to my fatigue. And keep a journal of my energy each day with one, meaning I was exhausted, two, I was tired, three, I was feeling okay, I. But less than 50% of the time today. And four is I was feeling energetic more than 50% of the time most days this week. And it's really important for them to be able to have some sort of anchored, anchored Likert scale to rate themselves on. They said they're going to start changing one thing each week. So then under that, they're going to identify the things they're going to change. Now, that's in the what will I do? Column. In the how will I do this column, we fill that out together. So learning about the causes of fatigue in general, I might put in there, review the handouts provided by Dr. Snipes. Dubai, that would be a week from now. And what reward are they going to give themselves when they do it? What treat, what thing are they going to do to congratulate themselves? And it could be a night off, it could be. It could be a bubble bath. It doesn't have to be anything huge. Then going down to the next one, identify which of those things is causing my fatigue. So then they really need to look at themselves and go, okay, which parts of this stuff that I just learned about apply to me? How will I do this? By reviewing the handouts that Dr. Snipes gave me and making a list of the things that caused my fatigue. Dubai a lot of times I have them do these first two things in the first week, but you could have them spread it out over two weeks and you see where we're going from there. So it's very methodical, but it helps clients really start conceptualizing what they're doing and seeing progress. And we'll talk about why this is important. Now, for reassessment, you can do this in group or individual. And like I said, I really think it's important to do at least a short reassessment every single week, especially if you're doing IOP or residential. If you're in once a week outpatient, then you may have them complete a self reassessment and bring it in with them. So you're not using a lot of your clinical time, you know, going through filling out the worksheet. But the worksheets are really helpful. I love using them in group for whether it's residential or intensive outpatient. And we, we have one group each week where we review treatment plan progress and each person shares what they were supposed to do that week, what they actually did that week, and if they didn't achieve all of their goals, why they didn't. It allows people to get support and encouragement from their peers, it allows them to get kudos from their peers, and it also allows them to be able to gain a little bit of insight. So each person keeps a copy of their treatment plan with them and they identify, you know, my goals for this week, goal one. And they write in what goal one was, was it accomplished, yes or no. If no, identify the obstacles what kept you from accomplishing that goal? Was it motivation, resources, knowledge? New problems that crept in? What kept you from, you know, doing it? And what changes may need to be made to your treatment plan to address these obstacles? Now, I will tell you all auditors love this stuff. If you take these reassessment worksheets and you include them in your file, if you've got an emr, you may have to scan it in and attach it as a PDF to the electronic medical record. But auditors really like seeing client participation in this treatment process. It's important when you're talking with your clients, when you're talking about the different things that they're doing to help them identify what they're doing. Well, when they have an obstacle, for example, and this is the reason I love groups, a lot of people in the group may say, oh, I've been there and this is what I did. They can provide each other pats on the backs or pull ups, which is one of the things that I reasons that I really love group. When you do this reassessment in group each week, like I said, it becomes part of the record. So that becomes part of your note for that day, or usually the brunt of your note for that day. And it also serves to guide future treatment planning issues. So by doing these with the client, you're empowering the client. You're doing them most of the time during session because you're helping the client learn how to set goals. You're helping the client learn how to engage in rapid cycle change. They notice that there's a problem, figuring out how to assess that problem and start taking steps towards improving that issue. I have never had a person balk at doing these things in group or in session because we do it concurrently. Y' all know, I typically do my progress notes concurrently as well. At the end of session, the last 10 minutes, we do the first 50 minutes, you know, like normal. The last 10 minutes, pull out my handy dandy progress noting sheet and we go through and I together talk about, okay, you know, I asked the client, what were the highlights? What were the most important things in your mind that we talked about today? What did you accomplish between last week and this week? You know, what were the goals that you accomplished? What are your goals for next week and what are are any referrals or anything that we talked about that that you're going to do? And I write all those things down. You know, we're just kind of wrapping up, putting a great big summary on what we did in Session that helps the client refresh what they've done in session. The client signs it, I sign it, I make a copy. Yes, I still do things by hand, make a copy and I give it to them. That way they have evidence of the progress they made. They also have notes about what they're supposed to do in the upcoming week and any referrals that are needed. So by the time they leave, yes, we've spent the entire 60 minute session. However, my paperwork's done and they have information that they're taking with them. So I really think it's important for a lot of reasons to incorporate as much of your documentation as you can into session and include the client in the process. The auditors often want to hear, you know, treatment plan. I can't tell you how many times I had auditors say I want the treatment plan to be in the words of the client. Well, it can't be very much more in the words of the client if the client's writing it with you. Same thing for the progress notes. The auditors really want to know what's the client's perspective on things. And by doing some of your paperwork with the clients, it can really help them be part of the process. A good assessment and integrative summary forms the foundation of an effective treatment plan. When clients participate, they are empowered and more motivated. They have a dog in the race, so to speak. Assessment instruments like the FARs, CANS or locus help the client and clinician identify and define the problems. And reassessment activities can help the client see progress, get support and make adjustments to promote rapid cycle change. And I know that concept of concurrent documentation is a little bit overwhelming to people because that's not what we were taught in graduate school. But if you explain to clients why you're doing it, you know how it benefits them and just make it a standard part of the process. Like I said, I can tell you I have not had a single patient in almost 20 years, have an issue with it. The Fars, the Locus and the PowerPoint are in your classroom. So when you go in there to take your quiz, you can download that and you know, the rubric and everything we talked about in the PowerPoint are in there for you.