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Forms & Documentation

Although the industry still requires a lot of paperwork to treat, you can now do most of the work through an electronic health record (EHR) system. Most EHR's should supply the paperwork you will need and they even make a way for you to add your own branding/ logo.  BHealthy paperwork is available for purchase for $25.  We also offer our policy manual for $100. We know it's pricey, but it took us two interns and 6 months to draft it, we're saving you the headache and cost :) Our paperwork was approved by OHMAS (Ohio department of mental health and addiction services) so your safe to adopt it and make it your own. Some tips and tricks will follow.

If you have paperwork you are willing to share, please contact us and we would love to add it to our library!  

Helpful Links:

HIPPA & Privacy

HIPAA

HIPAA for Minors

Health Information Privacy to professionals

Health Information Privacy to Others

Health information Privacy to friends & Family

Health information Privacy to police & Fire

Health information Privacy for mental health information

Health information Privacy for substance and alcohol

Summary HIPAA Privacy Rule

Summary of HIPAA Security Rule

HHS's HIPAA Mental health FAQ

Link: HealthyPlace Psychological Exams (Source Sondermind)

Link: Psychological Tests (found on Mental Health America)

Document with Pen
Commonly Used words in Clinical Documentation

Acknowledged

Actively Listened


Addressed


Advised


Advocated


Asked


Assisted

 

Assisted client in

Asked

Affirmed

Challenged

Challenging

Coached

Checked In
Clarified
Collaborated
Commended
Confronted
Conducted
Conveyed
Crisis Intervention

De-escalated

Demonstrated

Developed

Directed

Discussed

Educated


Empathized


Empowered


Ensured


Established


Explained


Explored


Expressed

 

Encouraged

Explained

Examined

Explored

Evaluated

Facilitated

Focused on

Focusing/Refocusing
Framing/Reframing

Gave homework

Guided

Goal (setting)

Highlighted
Honoring
Identified
Information Giving/Gathering
Informed
Interacted
Interpreted

Instructed

Interpreted

Introduced

Inquired about

Joined

Listened
Modeled

Observed
Physical Activity
Played
Praised
Presented
Probed
Problem Solving
Prompted

Paraphrased

Performed

Planned

Practiced

Praised

Prompted

Provided

Redirected

Reflected back

Reframed

Refocused

Reinforced

Responded to

Reviewed

Role played

Rapport-building
Recapped
Recommended
Redirected
Reflected
Reflective Listening
Reframed
Reinforced
Reiterated
Reminded
Reviewed
Role-played
Social Skills Practice
Suggested
Supported

Set boundaries

Shared

Supported

Trained

​Teaching/Lecturing
Urge

Validated

Documentation: While there are multiple ways to document, the easiest and most efficient is narrative note taking, ie. taking notes during the session verbatim as you and the client interact. Most EHR's have a scan upload feature. Its fast, easy and note submission takes 5 minutes or less. We recommend taking a class on documentation with your local board for CEU's (continuing education units). NEVER give medical or legal advice. Practice within your scope. Notes should always be unique to the client, even in groups.

 

Always apply ASAM when working with state insurance. Get training in ASAM if you are not familiar. The ASAM manual can be purchased online.  The Asam Criteria is treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions 3rd ed. Edition. It's important to learn it and use it in your work.

 

There is no one way to document, try several and see what fits you and your flow during sessions. Remember, go through the paperwork with the client, a proper intake is informed consent and going through the biopsychosocial. Anything you write down becomes permanent record. Take good notes but don't overdo it (in case notes are subpoenaed, you want the client to be protected).

Forms Templates:  Forms may vary by state. Talk to your state licensing board.

Practice Paperwork Packet  for The Columbus Wellness Center

Columbus
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