Part 4: Documentation of REP in Electronic Notes

Section 3: Teaching and Learning Together Part 4: Documentation of REP in Electronic Notes

Objective:

1. Provide an example of how to document interactions provided using the START model

One of the helpful features of the START model is that it provides a nice framework for writing notes in the electronic record.

SOCIALIZE: This part of the note focuses on the ways in which the provider attempts to connect with the client and tries to build an alliance

Start out with “Client and this CRS (refer to yourself in the third person if that is your agency’s practice) discussed how his/her day is going, checked in on (specific thing client is interested in) and if there is anything immediately in mind to discuss today” (perhaps an “episode” or a conflict with someone, or just sharing nice or difficult experiences during the time between sessions).

If there was some type of take-home work discussed in the previous session, see below for ways to document take-home work assigned between sessions.

We discussed client’s take-home work from last session which was ________________________.

Client did not complete the take-home work (forgot about it) and so we discussed and identified… Barriers to remembering that take-home work was given

How to do the take-home work, and questions they have about that

Strategies he/she agrees are likely he/she will use to follow through

Go through the take-home work and re-explain at this session if needed

o

o Reviewing the take-home work over and over again is common (due working memory difficulties).

Client verbalized better understanding what he/she needs to do

If client completed the take-home work

o

o

o But did not demonstrate understanding of how to do it, so we reviewed again. Client verbalized understanding of take-home work

Take-home work demonstrated that client had some insights from the activity. Those insights were…. This CRS affirmed client’s movement toward recovery goals

TARGET: This item is intended to document the client’s Targets so that there is an agreed-upon focus for the meeting that is relevant to the client’s recovery goals. Tasks are different than targets. This is also the place where the case manager would address medical necessity of the target

Task= Activity to be completed (e.g., application, appointment, shopping). Note that a “task” is different from a “target.” o

Target= an area “targeted” for exploration or development: often a skill to develop or reinforce along the way to completing the task (e.g., coping strategy for voices to lower distress and help with completion of task or encouraging client to challenge their self-doubt and attempt to complete steps of a task in order to encourage independence).

Documentation example: We agree to work on skills to encourage independence (then explain the skills –begin to develop a daily schedule, learning how to use their cell phone), e.g. for the purposes of gaining independence and ensuring safety/regulating emotions to reduce impulsivity/reducing distress/reducing voices/ etc. (Medical necessity reference

point)

Another way to think about the target is to ask the question: What keeps the client from being able to complete the task on their own? (E.g. being confused, low self-esteem, family issues, symptoms, hospitalization, outright refusal, etc.). Addressing barriers are another way to indicate medical necessity.

Documentation example: Client was concerned about oversleeping. We agreed to discuss the reasons it is difficult to get up at the time client wants to so that we can develop a plan to get to help him to get to appointments and work on time.

ACTION: The focus here is to document the client’s and provider’s efforts to develop a plan of action to address the concern (distress) and/or takes steps toward an important client goal. It is important to document evidence of collaboration and shared decision-making as well as medical necessity for the target and action.

Documentation example: We agreed to work on getting client’s identification for work. We identified the primary challenges to completing this task included client’s difficulty concentrating and anxiety. Client began application and CRS helped client think through responses as needed. We discovered client was more anxious about working than he originally thought. We talked about working on the skills to complete the application and we identified two skills to practice in order to lower anxiety.

Note about how the client is responding to the task and to a move toward independence (client was reluctant, client was motivated, client was angry…)

o Client responded well to idea of relaxation breathing. Completed most of application on his own

Is there anything that needs to be done to support this client with this particular skill?

o Client reported that having reminders of the relaxation skill is helpful. We wrote out reminder cards and CRS will periodically provide reminders to use these cards

This part of the note needs to reflect the client’s identification of what he or she wants from treatment, how they want treatment to go, what they are wanting in terms of support, and what you both are collaborating on to get them there, etc.

Client can see that by improving skills in managing anxiety and completing the application will help get to recovery goal of working

REVIEW and FEEDBACK (from the client): There are two main points to this item: 1. Ask client to comment about the meeting: what was the skill, strategy, educational point of the meeting, (Review) and 2. Elicit the client’s feedback about what was helpful and not helpful from the encounter and give the client permission to recommend changes (Feedback).

Client was unable to remember what occurred during the session.

o

This CRS worked with client by giving reminders

o This CRS reviewed the session and made notes so client could refer back and gave the client a copy of notes to take with him/her

Client was able to review the session well and needed only small reminders

Client was able to completely remember the session and has a solid understanding of take-home work and its rationale

Client stated “x, y, and z” was most helpful in today’s session Asked client for feedback to improve meetings and client reported…x, y, and z. We agreed to make this change.

TAKE-HOME WORK: The primary focus of this item is to record work that is to be completed outside of the MHP meeting that will help the client move toward

his/her recovery goals.

We discussed what to do between session and client decided to practice the breathing relaxation twice a day to reduce anxiety. Client will report back on how this went at next session. Case manager agreed to look for support resources for work to discuss at the next meeting.

Example of Electronic Notes Using START

Client agreed to talk more about the bus rides he is taking (demonstrates collaboration). CRS provided information about the dangers of riding busses all day and he verbalized understanding why riding the bus is dangerous to him at this time (demonstrates client’s understanding in a behavioral way). We discussed other things he might do to take up his day while having to shelter at home (demonstrates collaboration). Together we came up with a summary list of the reasons for caution and a list of alternate activities and gave them to him at end of session (here you have devised a technique for him to use between sessions and a built-in reminder). We discussed the need to practice these activities daily if he can. Client agreed he could do one thing from the list. Client was able to go into the grocery store with me and collect the things he needed. Client required some direction to stay on task and we reviewed potential benefits of having a pre-written list (throughout this

note we have action and take-home work covered)

Client was able to remember what we discussed in terms of activities other than riding the bus. He showed strong engagement today (highlight strengths) by taking the notes and agreeing to practice activities (take-home work) and report back how that went at next session.

o Client indicated that this was a helpful discussion (session), he/she stated he like being able to create the list of ideas and Use phrases that sound the most like you. The note should reflect the recovery that he enjoyed the outing (feedback). practices you used (connection, collaboration, normalizing, developing coping ideas) that addresses an important target that indicates medical necessity (memory problems and risk factors in the above example). It should be clear from the note the steps you took and the things to follow up with.