Special Topics

Module Seven

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• Introduction*
• Updating and Review*
• Diagnostic Assessment Review*
• Functional Assessment Review*
• Individual Treatment Plan Review*
• Planning for Discharge*
• Documenting Evidence- Based Practices (EBP)*
• Electronic Records*

Electronic Records

Electronic medical or health records are increasingly being adopted into behavioral health rehabilitation programs.They bring strong advantages to programs.

Special care should be taken in the following areas of documenting rehabilitation:

• Checklists and checkboxes need to allow for specific, individualized information about each recipient.This is especially true in the areas of symptom and functioning checklists.
  • Many recipients’ have hallucinations, but knowing how they impact this specific recipient is critical.
• Treatment plan templates also must allow individualization.  
  • This allows goals to be tailored to the recipient’s recovery goals and for objectives to reflect small incremental progress.
• Drop-down menus that mandate linkage between assessments and ITP’s or between ITP’s and progress notes are extremely helpful.
  • Care needs to be taken to ensure that the note reflects the goal that is pulled down or that the treatment plan reflects the assessment data that is pulled down.

Click here for further information about electronic records.