Provides quality clinical services to clients through individual, group, and/or family therapies and documentation is timely, concise, relevant, and meets payor/legal requirements.
- Services reflect accepted standards of care and are based on clinical evidence.
- Completes treatment plan which includes measurable goals, expected length of treatment, and planned interventions on every patient.
- Interventions reflect a knowledge of age-appropriate behaviors
- Cognitive behavioral therapy and other brief therapies are utilized whenever appropriate
- Group facilitation reflects expertise in group dynamics
- Documentation reflects interventions of clinician as well as responses of clients
- Each patient visit (including groups) is documented reflects active treatment based on the treatment plan, progress towards goals, and patient's response to treatment; progress notes are congruent with department policies/procedures, e.g. ‘DAIR' charting.
- All hand-written documentation is legible and is written on appropriate department/MMCI forms.
- Completes all documentation and correspondence as expected by payor whenever necessary
- National Patient Safety Goals are incorporated into the treatment and goals of all patients
- CPI certification is current and utilized in the care of all patients
- Demonstrates Joint Commission Inspection readiness at all times in performance of clinical responsibilities
Completes initial and ongoing assessment of client.
- The initial assessment is dictated or within 2 business day of the initial visit
- The assessment includes all five diagnostic axes. (DSM-IV) and all bio- psycho- social realms
- The assessment includes a description of the presenting problem as well as a summary of the behavioral illness(es)
- The assessment includes a brief summary and clinical impression of the clinician
- Information from significant others is included whenever available and appropriate, with all necessary releases completed accordingly
- Obtains pertinent information from other sources, i.e. teacher, PCP, counselor, etc. whenever possible for purposes of conducting a thorough assessment
- Established targets for chart review indicators are consistently met. Target is 90% compliance.
- Preparation for and participation in weekly meetings with psychiatrists is consistent
- Patient is ongoingly assessed during each subsequent visit, and this is documented in the progress notes.
Provides case management, referrals, and discharge planning
- Assists with obtaining authorization for visits whenever necessary.
- Coordinates treatment as well as discharge with significant others, employers, schools, involved welfare agencies, psychiatrist, and any other care provider as appropriate
- Identifies clinically appropriate level of care; facilitates transition between levels of care within the Behavioral Health and Service Line continuum of care
- Provides timely feedback to referring party with appropriate releases
Productivity reflects efficient and appropriate use of time.
- Provides appointment times which meet customer needs
- Due to high no-show rate of patients, overbooks appointments daily (minimum of 9 patients for 8-hour day) obtain approval for anything else.
- Clinician target productivity is 80% of billable hours.
- Makes self available for urgent clinical services whenever possible.
- Will facilitate group therapy session/week if clinically appropriate clients are available.
- Participates in non-clinical activities as approved by supervisor