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
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 her annual re-assessment and 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, substance abuse, and family involvement. Completed risk assessment and… (other documents that were completed).
R: Member was cooperative and engaged.
P: Will complete pages 1-3 of the annual re-assessment based on member’s report and information provided by referral source and/or contained in her chart.
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 annual re-assessment.
I: Completed p. 1-3 of the annual re-assessment (presenting problem, history of present illness, past psychiatric history, recent and past harm, current/past drug and alcohol use, current and past medical status, substance abuse, family involvement, MORS history, and other community providers) based on information member provided on _____________ and obtained from _______________ (referral source, her chart, her doctor, her treatment team, etc. Some things, like the 6-month history of MORS scores, we can’t get from the client).
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 different "I" sections)
G: Deborah is a 39 y/o single Caucasian female. T/W met with member to review her Annual TCP 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 6-month objectives on her current plan: 1) Showering 3x/week; 2) calling and arranging at least 3 psychiatrist appointments herself; and 3) meeting with her PCP at least once. Deborah accomplished all 3 objectives. Engaged Deborah in a discussion of her hopes and dreams, her strengths, and her perception of the barriers she needs to overcome. Developed 2 new 6-month objectives and added them as an addendum to the current plan. Completed Risk Assessments. Updated/added PHI releases.
I: Reviewed Deborah’s current objectives with her: 1) “Deborah will maintain stable housing in at least 8 of the next 12 months”; 2) “Within 12 months Deborah will have applied for SSI benefits”; and 3) “Within 6 months Deborah will be able to demonstrate at least 3 anger management techniques”. Deborah was able to demonstrate 3 techniques to this writer so she has accomplished her 6-month goal. She has not accomplished either of the 12-month goals yet, but is making progress and feels she will be able to achieve them within the next 6 months. One new objective related to employment was agreed upon and added as an addendum to the current plan. Also reviewed the CFS with Deborah and determined it was still accurate, so no changes were made. Completed Risk Assessment.
I: Met with Deborah at TAO Program. Reviewed her life circumstances, the CFS, and progress towards current objectives. Deborah has now moved into a Shelter + Care apartment, successfully accomplishing her #1 objective. She has not yet accomplished her other 2 objectives, related to anger management and obtaining employment, but still has 6 more months to achieve them and asked to leave them unchanged. Dated and initialed “Completion date” for Objective 1 on TCP. Updated CFS 1 on addendum page to account for change in living arrangements. Completed Risk Assessment.
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 2 of the 6-month goals, looking for work at least 3x/week and identifying (today) 3 triggers to angry outbursts. Her 3rd 6-month objective, explaining the pros and cons of taking meds, is expiring unaccomplished. Her 12-month objectives are all still current and relevant, so no changes are being made to the plan at this time. Completed Risk Assessment. Congratulated Deborah on her progress.
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 TCP. Deborah asked if this could be increased to 3x for the second half of the Annual plan. T/W agreed and added the updated objective on the addendum page. Interventions for this objective will remain unchanged. Completed Risk Assessment. 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.
Assessment and Care Plan notes for LPHAs
First note: (66 FTF, 66 Svc, 8 doc)
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. I may need to meet with him a second time to clarify some of the information he provided today.
Second note: (0 FTF, 121 Svc, 6 doc)
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 with him on 4/21/20, consultation with his CM and MD, and a review of his chart. Time spent reviewing chart and consulting with CM and MD are not included in service time on this note.
R: Frank was not present for today's service.
P: Plan is to review the completed CP 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: (26 FTF, 26 Svc, 5 doc)
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.