ASSESSMENT & TREATMENT / Person-Centered PLAN

ASSESSMENT & TREATMENT / Person-Centered PLAN

See Appendix B: Updated PCP and Comprehensive Clinical Assessment Protocol

An assessment is completed for a client, according to the governing body policy, prior to the delivery of services, and includes, but need not be limited to:

• The client’s presenting problem

• The client’s needs and strengths

• A provisional or admitting diagnosis with an established diagnosis determined with in 30 days of admission.

• A pertinent social, family, and medical history; and

• Evaluations or assessments, such as psychiatric, substance abuse, medical and vocational, as appropriate to the client’s needs.

When services are provided prior to the establishment and implementation of the treatment plan, hereafter referred to as “the plan”, strategies to address the client’s presenting problem shall be documented.

The plan is developed based on the assessment and in partnership with the client or legally responsible person or both, and implemented within 30 days of admission for clients who are expected to receive services beyond 30 days.

The plan shall include:

• Client outcome(s) that are anticipated to be achieved by provision of the services and projected date of achievement;

• Strategies for working toward goals;

• Staff responsible;

• A schedule for review of the plan at least annually in consultation with the client or legally responsible person or both;

• Basis for evaluation or assessment of outcome achievement;

• Written consent or agreement by the client or responsible party, or a written statement by the provider stating why such consent could not be obtained.

COMPONENTS OF A CLIENT RECORD

A client record is maintained for each individual admitted to the agency, which shall contain, but need not be limited to the following:

• An identification face sheet which includes:  

                      Name (first, last, and middle, and maiden)

                    Client record number

                    Date of birth

                    Race, gender, and marital status

                    Admission date

                    Discharge date

• Documentation of mental illness, developmental disabilities, or substance abuse diagnosis coded according to the DSM IV;

• Documentation of screening and assessment; treatment/habilitation/PCP or service plan

• Emergency information for each client, which shall include the name, address, and telephone number of the person to be contacted in the case of sudden illness or accident and the name, address, and telephone a the client’s preferred medical physician.

• A signed statement from the client or legally responsible person granting permission to seek emergency care from a hospital or physician;

• Documentation of services provided

• Documentation of progress toward outcomes

• (If applicable) documentation of any physical disorders diagnosis according to International Classification of Diseases (ICD-9-CM)

The Ship Group Community Services ensures that information relative to AIDS or related conditions are disclosed only in accordance with the communicable disease laws as specified in GS 130A-143.

See The Ship Group Community Services Care Consumer Record Index/Outline in Appendix G of this manual.