Client Charts

I will do only the patient demographic part and the provider or someone for clinical has to complete the form. I still don't understand why Johana or any MA can complete the patient demographic part on vase of the list that I provide to them but anyway I will do that part so they can't said that our billing department don't want to cooperate on this process.I know we shouldn't not be responsable for this but we need to recovery that

Session 1: During this face to face session on 8/8/16, MHS addressed the following ADLs: Medication Monitoring, Community Involvement, and Functional Skills. MHS asked the client if he had taken his medication today. The client reported that he did take his medication. The client mood was cheerful and inviting. The stated he is still looking forward to working when he can. The client stated he gets bored sometimes just sitting at home. The client requested to be accompanied to the library. MHS praised the client in making progress for independent living (20 mins). MHS accompanied the client to the library to view educational videos on how to display appropriate social skills in the workplace (25 mins). MHS suggested visiting the library gives

I currently work at an SMI clinic for TERROS and I selected an intake form off of the internet instead of the intake for my work because our intake is a template that generates into a document once signed by all appropriate parties. I must say this random mental health intake form I found is extremely similar. I think these forms are now somewhat standardized and having just recently started filling out assessments of this nature and doing service plans with behavioral health recipients. I must confess it is difficult to get all of these answers out of clients and to keep their attention long enough to complete this paperwork. I feel often times we must resort to generic answers that do not give us a full understanding f who these people are and what their needs are, but it is a good resource to have a basic understanding of a client and when sharing information with other people on the clinical team good note taking skills and complete forms makes communication and client service much more efficient.

I believe that the intake form reviewed all necessary questions needed to determine the client’s social and medical history to develop personalized goals for the client’s individualized treatment plan. I will begin to discuss the areas that the intake form reviews in order to obtain the necessary information to develop a treatment plan for the client.

Some of the documents will be mandated such as the consent for services and client disclosure. Others could be required by the particular referral agencies such as the Human Services required safety needs assessment. Four Feathers Counseling has a treatment plan goal document that it requires all cases to complete regardless of referral agencies requirements.

However, during this process clients will seek paperwork two weeks prior to their discharge date and complete the given packet. In this packet client will answer questions pertaining to their financial status. Depending on the collected information, our facility will debate whether or not the clients had insubstantial funds, in which we will grant funds for the client to attend any local program of their selection, under the circumstances that the program is less than $300 per month, for only a maximum of three months per year. If an extension of longer than the allotted time is requested, the patient must apply. Consumers of all ages can be provided service in this program. Moreover, in order to qualify for boarding at the facility, the consumer must be over 25 years old, diagnosed with PTSD and have been discharged from a

Today I organized documents for case managers because there are some new clients that are being processed. There is a form that must be completed on each client which is an Intake form. This form is the form that Case Worker fill out when a new client is introduced into the Redeploy program. There are two different forms Outer Counties and St. Clair counties. On the document it has several questions such as name, address, education, health, and use of what substance, religion, and family income. This is the first form I saw in each client’s file because this is important to know who file you are looking at and the background on the client.

Patient Care Coordinator faxes medical record authorization(s) and upload the signed authorization(s) to EeMR under the “Consent” folder.

Meeting: During intake client was informed and explained the Rules and Regulations of the facility. Case Manager also reviewed orientation packet with client. Client agreed with all rules, signed forms and was issued a copy of all documents signed. Client was informed that she is to comply with the following: Client must meet with assigned Case Manager on a weekly basis. Client must refrain from committing acts which endanger the health or safety of others or that substantially and repeatedly interfere with the orderly operation of the facility, including

The client, Julie*, called into the Crisis Center Hotline looking for immediate shelter for herself and her two young children. At that time, our shelter was not full and therefore had space for the mother and her children. I went through the procedural routine of making sure that she was not in the center’s blue books, a record of clients not allowed to receive shelter and/or services, and seeing if she had an alpha card already completed, this would mean that she was a previous client at the shelter and already had a file. Julie* did was not found in either source. At that point, I began to complete the shelter intake paperwork with her over the phone. The first two pages of the intake are completed first with the client. These pages find out more about the client’s demographics, her current physical and mental health state, how many children she has and if she could be pregnant at the time, her abuser’s demographics, and the presenting primary abuse occurring. I completed these two pages with Julie* and then from that point an approval staff member will tell you if you can complete the rest of the intake or tell the client that at the time we cannot offer them services. Julie* was approved to complete the rest of the intake paperwork. The majority of the rest of the intake paperwork is a more detailed explanation of the first two pages. These pages help the approval staff and I see if the client raises any major concerns and allows us to prepare for her stay

Step No. 2: Client must attend to all onsite and offsite medical referral including mental health counseling

When clients are admitted to the RTC, a legal guardian must accompany them in order to complete the initial intake documentation. Several intake procedures are completed within the first twenty-four hours of the client’s arrival. The intake process begins with consent forms (see Appendix X) that require a signature from the legal guardian, which gives the RTC permission to treat the client. The legal guardian is asked to complete any necessary Authorization for Release of Information (see Appendix X). Next, the lead nurse conducts the Intake Behavioral Health Assessment and Service Plan (see Appendix x) with the new client. Following this assessment, the client is asked to provide a urine sample to test for substances (see Appendix X) and the

Answer the following patient information questions using the table provided. Refer to figure 4-10 on p. 83 of Health Information Technology and Management for assistance.

As I’m in preparation of learning how to do intake and service new clients a vital part of intake is inputting the information obtained into the AIRS system. This past week I attended the airs monthly updates and report webinar and conference call. The discussion was about merging, intake, CTR data completeness and the linkage and navigation form. The Navigation and Linkage part was important as it relates to what my job title is. Learning the correct way to fill out the form and ensure that I’m completing the form properly is vital to make sure that the client information is being recorded properly. I have also been put on a waiting list to attend the AIRS basic training for august 18. All of the trainings and updates are made into tutorials online that I’m able to watch to give me an idea on how to input the client’s information according to the AIRS

Intake forms are a very important part of the treatment process. A good intake form will give you a good idea of where the client currently is and some of the client’s history. These factors that come from the intake form of what to discuss first with the client and where to begin treatment. It’s also good to use an intake form for documentation purposes.