Assessment (90899-6)

90899-6 is the code we use for treatment plans and 6-month reviews. Over the past 12 months, there have been major changes in how treatment plans are done. Right now, Case Managers (PSCs) are limited to doing the first 3 pages of the assessment. They can still do 6-month reviews, however. Below are examples of assessment notes by CMs, 6-month review notes (same for both CMs and LPHAs), and assessment notes by LPHAs.

 

Assessment notes for Case Managers

First note:

G: Member is a 35 y/o single Caucasian female. I met with her today to gather information necessary to complete p. 1-3 of the Psychosocial Assessment and to complete associated documentation.

I: Gathered information from member regarding her perception of her presenting problem, history of present illness, past psychiatric history, recent and past harm, current/past drug and alcohol use, current and past medical status, and family and social histories. Completed DTS/DTO Risk Screening and… (other documents that were completed).

R: Member was cooperative and engaged.

P: Will complete pages 1-3 of the Psychosocial Assessment based on the information I obtained today.

Second note:

G: Member is a 35 y/o single Caucasian female. This note is to account for time I spent completing p. 1-3 of her Psychosocial Assessment.

I: Completed p. 1-3 of the Psychosocial Assessment based on information member provided on _____________ .

R: Member was not present for this service.

P: Plan is to meet with my Team Lead, discuss the information I obtained, and turn the assessment over to him/her for completion.

These examples are just to give you an idea of how assessment notes should look. You don't need to copy them word for word. In terms of signing, initialing, and dating, the only thing you need to do is initial and corner date the first 3 pages of the assessment to match the date of the second note you dropped, where you documented developing those pages.

 


 

6-month review notes (same for CMs and LPHAs)

(One note with examples of 5 different "I" sections)

G: Deborah is a 39 y/o single Caucasian female. I met with her today to review her Care Plan at the 6-month point, monitor progress, and make adjustments to her plan if necessary.

I: Reviewed Deborah’s current objectives with her. She has three 12-month objectives on her current plan: 1) Showering 3x/week; 2) calling and arranging at least 3 psychiatrist appointments by herself; and 3) meeting with her PCP at least once. She has not accomplished any of these objectives yet, but is making progress and feels she will be able to achieve them within the next 6 months. Completed DTS/DTO Risk Screening. Updated/added PHI releases.

I: Reviewed Deborah’s current objectives with her: 1) Maintain stable housing in at least 8 of the next 12 months; 2) apply for SSI benefits; and 3) be able to demonstrate at least 5 anger management techniques. All objectives are for 12 months. She has not accomplished any of them yet, but feels they are still relevant and wants to continue working on them. Also reviewed the CFS with Deborah to verify that no significant changes have occurred. Completed DTS/DTO Risk Screening.

I: Met with Deborah at TAO Program. Reviewed her life circumstances, the CFS, and progress towards current objectives. Deborah has now moved into a CoC apartment, successfully accomplishing her #1 objective. She has not yet accomplished her other 2 objectives related to anger management and obtaining employment. She still has 6 more months to achieve them and asked to leave them unchanged. Dated and initialed “Completion date” for Objective 1 on her Care Plan. Updated CFS 1 on addendum page to account for change in living arrangements. Completed DTS/DTO Risk Screening.

I: Met with Deborah at TAO Program and reviewed her objectives with her.  She has both 6-month and 12-month objectives on her current plan. She accomplished one of the 6-month goals, looking for work at least 3x/week. Her second 6-month objective, explaining the pros and cons of taking meds, is expiring unaccomplished. Her 12-month objective is still current and relevant, so no changes are being made to the plan at this time. Completed DTS/DTO Risk Screening. 

I: Met with Deborah at TAO Program and reviewed her life situation, current objectives, and CFS. She has already accomplished one of her 12-month objectives, meeting at least 1x with the psychiatrist. Dated and initialed “Completion date” for this objective on her CP. Deborah asked if this could be increased to 3x for the second half of the Annual plan. I agreed and added the updated objective on the addendum page. Interventions for this objective will remain unchanged. Completed DTS/DTO Risk Screening. No other changes to the plan were necessary.

R:  Deborah was attentive and participated in the review of her plan.

P:  Will continue working with Deborah on accomplishing her objectives.

 



 

Initial Assessment and Care Plan notes for LPHAs

First note:

G: Frank is a 34 y/o single Caucasian male who was referred by AOT and enrolled in TAO three weeks ago. I met with Frank at the clinic today to gather the information necessary to complete his initial assessment and care plan. 

I: Gathered information necessary to complete pages 1-3 of the Intake Assessment (presenting problem; Hx of present illness; past psychiatric Hx; recent/past harm; drug and alcohol Hx; current and past medical status; family involvement in Tx; and family, developmental, and social histories.  Performed MSE (p. 4). Gathered information necessary to complete p. 5 (Hx of trauma; psychotropic med Hx; current Rx medications; and narrative summary) and p. 7 (Community Functioning Status). Helped Frank articulate a long-term recovery goal (having more friends and owning his own home) and 3 short-term objectives addressing barriers that are currently preventing him from achieving it.

R: Appears stated age; hygiene and grooming poor; eye contact normal for culture; motor activity slightly retarded; speech slow with poverty of content; slightly guarded; oriented x4; average fund of knowledge; mood “okay”; affect restricted; reports Hx of A/H but denies hearing voices today; associations unimpaired; poor concentration with possible occasional thought-blocking; judgment fair and insight fair; no apparent delusions or thought content disturbances; denies S/H/I.

P: Plan is to develop Frank's initial assessment and CP based on the information I obtained today.

Second note:

G: Frank is a 34 y/o single Caucasian male whose initial assessment and care plan are due 5/31/20. This note is to account for time I spent developing his initial assessment and treatment plan.  

I: Developed Frank's initial assessment and CP based on information I obtained from him during a face-to-face meeting on 4/21/20, information provided by the referral source, and consultation with his CM and MD to establish medical necessity, clarify diagnosis, and determine appropriate treatment.

R: Frank was not present for today's service.

P: Plan is to review the completed CP with Frank and obtain his approval and signature. (Or, to review it with Frank's CM and turn it over to her so she can meet with Frank, review the CP with him, and obtain his signature.

Third note:

G: Frank is a 34 y/o single Caucasian male. This note is to account for time I spent reviewing Frank's CP with him and obtaining his signature.

I: Met with Frank at the clinic and reviewed his new Care Plan. Went over the objectives and the proposed interventions by all members of the team, including Frank. He approved and signed his new CP.

R: Frank was cooperative and engaged.

P: Plan is to meet with Frank next week to discuss which objective or objectives he wants to start working on first.

 



 

Annual Assessment and Care Plan notes for LPHAs

(Adds a review of the member's expiring objectives to Note 1 to comply with the County requirement, "In the progress note that corresponds with the treatment plan update, the clinician should document whether or not goals from the previous treatment plan were met." Removes "helped member articulate a long-term recovery goal" from Note 1 since that doesn't need to change, and removes "information provided by referral source" from Note 2 since we rarely refer to that once clients are established).

First note:

G: Joe is 52 y/o single Hispanic male. I met with Joe at his R&B today to gather information necessary to complete his Annual Re-assessment and CP and to complete associated documentation.  

I: Reviewed Joe's current (expiring) objectives with him. He was not able to achieve his employment goal but did accomplish his goals of maintaining stable housing and learning anger management skills. Discussed the reasons why. Gathered information necessary to complete pages 1-3 of the Re-assessment (presenting problem; Hx of present illness; past psychiatric Hx; recent/past harm; drug and alcohol Hx; current and past medical status; family involvement in Tx; and family, developmental, and social histories). Performed MSE (p. 4). Gathered information necessary to complete p. 5 (Hx of trauma; psychotropic med Hx; current Rx medications; and narrative summary) and p. 7 (Community Functioning Status). Helped Joe prioritize his needs and come up with 3 potential treatment objectives. 

R: Appears stated age; hygiene and grooming poor; eye contact normal for culture; motor activity slightly retarded; speech slow with poverty of content; slightly guarded; oriented x4; average fund of knowledge; mood “okay”; affect restricted; reports Hx of A/H but denies hearing voices today; associations unimpaired; poor concentration with possible occasional thought-blocking; judgment fair and insight fair; no apparent delusions or thought content disturbances; denies S/H/I.

P: Plan is to develop Joe's Annual Re-assessment and CP based on the information I obtained today.

Second note:

G: Joe is 52 y/o single Hispanic male. This note is to account for time I spent developing his Annual Re-evaluation and CP.  

I: Developed Joe's Annual Re-evaluation and CP based on information I obtained from him during a face-to-face meeting on 9/21/20 and consultation with members of his team to determine appropriate treatment.

R: Joe was not present for today's service.

P: Plan is to review the completed CP with Joe, make any changes he feels are necessary, and obtain his signature.

Third note:

G: Joe is 52 y/o single Hispanic male. This note is to account for time I spent reviewing Joe's CP with him and obtaining his signature.

I: Met with Joe at the clinic and reviewed his new Care Plan. Went over the objectives and the proposed interventions by all members of the team, including Joe. He approved and signed his new CP.

R: Joe was cooperative and engaged.

P: Plan is to meet with Joe next week to discuss which objective or objectives he wants to start working on first.

 

All PHI has been de-identified per HIPAA Privacy Rule