Rula’s team of Care Coordinators manages requests for most higher level of care (HLOC) needs by finding resources to support mental health recovery. To ensure we are locating and linking your clients to the best and most appropriate resources, clear and concise documentation is of the utmost importance. 

A clinician's documentation plays a crucial role in that it enables your client to access the needed services or supports and captures any possible barriers. Missing and/or minimal documentation does not speak to the clinical need for the service or program you’re recommending. 

It’s best practice to ensure that all documentation in your client’s chart (e.g., progress notes, treatment plan, and any collateral contacts/blank notes) is detailed, completed, and signed. 

What should be documented in the client’s chart?

Chart content should include the following:

• Details about their current symptoms
• Assessment scoring & review of these scores with the client (over time)
• Presenting Situation and Current Clinical Status, including:
  • Current precipitant, history of treatment
  • Current mental status including risks and safety issues
• Diagnosis(es): upon initial assessment and any changes. Note: ensure you’ve clearly documented the reasoning for the change including:
  • Symptoms
  • Functional impairment
• Any known medical Issues
• Plan of treatment to stabilize the situation, evaluation of changes implemented and effectiveness.
• A summary of medications, including quantity provided, prescriptions given, and affirmation that any prior authorizations for medications have been obtained (if applicable and/or known).

How to provide clinical rationale on the care coordination form

In the space provided on the Care Coordination Form (screenshot below), make sure to include the following: 

• The “why” behind the request
  • What occurred that prompted the request for this individual?
  • How will this request support this individual’s behavioral health journey?
• Details about their current symptoms
• Presenting Situation and Current Clinical Status, including:
• Current precipitant, history of treatment
• Current mental status including risks and safety issues
• Diagnoses: upon initial assessment & and any changes to this
• Any known medical Issues
• Medications: (All) reasons, effects, side effects and changes
• Plan of treatment to stabilize the crisis, evaluation of changes implemented and effectiveness.

• A summary of medications, including quantity provided, prescriptions given, and affirmation that any prior authorizations for medications have been obtained (if applicable and/or known).

Examples of documenting clinical rationale on the care coordination form

IOP - Mental Health

I’ve been meeting with this client for [amount of time] with little to no improvement in symptoms such as debilitating anxiety which is impacting their personal life but also seriously challenging professional life; there has been limited improvement in presenting problems of constant worrying fear of impending doom, despite consistent and regular attendance of weekly sessions in addition to this therapist providing evidence-based CBT interventions and targeted treatment planning. client expresses they feel they're“suffering” but also ambivalence about change. C-SSRS scores have remained moderate to severe over the past 2 weeks. 

IOP - Substance Use

Client reports failure to obtain prolonged sobriety in her adult life from alcohol - functional alcohol dependence appears to be present, with at home, social, and at times daily drinking of hard liquor. She is seeking a higher level of care through an IOP to specifically help her reduce and/or eliminate her drinking, to gain sober life skills. She is in need of more intensive and frequent support than individual outpatient therapy can provide alone, with a targeted focus on impulse control, social pressure resistance, and self-management for alcohol use.

Partial Hospitalization (PHP)

The client reports persistent & continuous feelings of depression along with a progressive increase in scores on their PHQ-9 over the past few weeks. Although initially feeling some improvement upon starting intensive outpatient groups, the client now describes a worsening of their depressed mood. Client is currently prescribed antidepressants (Wellbutrin XL, 150 mg once a day) and reports taking these as directed; next appointment with prescriber is on [date]. client acknowledges the effectiveness of their medication in reducing emotional pain and impulsivity, yet they continue to express and demonstrate decompensation such as: daily feelings of hopelessness, avoidance of all social engagements/interactions, poor hygiene (reports not bathing or washing up for days at a time), a significant decrease in appetite, thoughts of death/dying but continuously denies intent/planning (safety plan completed with client on [date]. 

Psychological Testing Requests

Rula’s Clinical Quality team does not recommend referring clients for the sole purpose of diagnosing ADHD. ADHD is fundamentally diagnosed through history and psychiatric evaluation, and often insurance will not cover neuropsych testing for ADHD diagnosis (especially in adults), as there is no research showing neuropsych testing to be necessary or accurate. This is due to many factors, including poor sensitivity of tests for higher-level executive function deficits, and the testing environment that removes the environmental factors that affect function in daily life for people with ADHD. 

Please make this provisional diagnosis on your own and/or consider referring to an adjunct service such as Psychiatry and/or rematching to another therapist who specializes in ADHD if/as needed based on your clinical recommendation.  

Example 1: Bulleted list  

Testing is needed to alter the course of treatment in the following ways:

• The parents can pursue ABA therapy for treating ASD. 
• The therapist can educate the client regarding his diagnosis
• The client can understand his diagnosis and treatment in a more thorough manner
• Treatment goals will be focused on the correct symptoms
• Correct Interventions will be applied
• Psycho-social accommodations can be asked for and made appropriately

For more information about when to refer someone for psychological testing, see the help center article, HERE. 

Example 2: Paragraphed 

The client and clinician would like psychological testing to address whether or not the client has ASD. The rule-outs or other diagnostic uncertainties the clinician and parent have concerns about is ADHD and Anxiety-related disorders. 

The significant presenting symptoms are: the client has an abnormal social approach but has learned to mask. He would prefer to be alone. He does not initiate social contact but will respond and then is tired afterward. He has difficulties making and maintaining friends. He has a lack of interest in being social. He does not like being in crowds. When he is with children he will not initiate contact unless prompted and/or will yell at everyone and demand rules be followed and fairness demanded.  He is sensitive to textures and tastes. Has to have a standard routine, insists on sameness. He needs to be told the plan for the day or he has a tantrum/meltdown. He has meltdowns with adjustments and changes. The client has rigid thinking patterns. He is extremely argumentative and noncompliant. He is noncompliant with non-preferred tasks. He has to be bribed. He is not interested in eating. The client is also extremely anxious and cautious. He has fixated interests that are abnormal in intensity and focus. Before the age of 5, he had a hard time self-regulating, He would have tantrums and meltdowns. He had difficulty being with crowds of people and wanted to be alone. He was a horrible sleeper as a baby. He always wanted bland foods and called everything spicy. Sensitive to clothing. He had/has sensory issues and noise sensitivity. 

Example 3:

client is currently diagnosed with F33.1 Major Depressive Disorder, recurrent, moderate & F41.1 Generalized Anxiety Disorder. Being tested for Autism Spectrum Disorder (ASD) diagnosis will possibly allow us to explore and focus on different interventions as well as updating goals to match ASD related behaviors, processing, and functioning. Additionally, psychological testing might benefit this client to determine ASD diagnosis, making them eligible for additional accommodations with studies and housing in their first year of college.

Psychiatry Referral Example

Client is demonstrating possible symptoms of ADHD. The client reports persistent & continuous feelings of depression & anxiety along with progressive increase of scores on their GAD-7 & PHQ-9 over the past few weeks. Provisional diagnosis of, F90.9 ADHD, Unspecified, was given by this clinician on [Date] due to client demonstrating and communicating the following to this clinician: difficulty concentrating and focusing, frequently making careless mistakes – for example, in school work, being unable to stick to tasks that are tedious or time-consuming, constantly changing activity or task, hyperactivity and impulsiveness; unable to concentrate on tasks, acting without thinking, interrupting conversations, impulsivity. This clinician recommends this client is evaluated for further exploration of provisional diagnosis and medication management as this may benefit client’s ability to manage symptoms and improve work/school functioning.