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Behavioral Health Best Practice

 

 

 

Behavioral Health best practice encourages providers to maintain appropriate clinical documentation:

 

Type of documentation: Description: Links:
Treatment Plan A written document containing a patient’s goals and objectives for treatment, as well as proposed interventions and target dates for completion. Goals and objectives should be written in measurable terms so both the provider and patient can track progress and know when goals are met.  Example   
Progress Note Progress Notes are the part of the medical record where the provider records details to document a patient`s clinical status or achievements during the course of treatment. Example  
Measurable Goals Examples of measurable and non-measurable treatment goals. Example
CPT Tips post 1/1/13 The letter provides guidance and direction on correct use of new CPT codes as of 1/1/13. Provider Letter
CPT Frequently Asked Questions (FAQ) Frequently asked questions about the new 2013 CPT codes with answers provided by the National Association of Social Workers (NASW) and the American Psychological Association Practice Organization (APAPO).

CPT FAQ (NASW)

CPT FAQ (APAPO)

CPT Q&A (APAPO)

 

With the release of DSM-5, the American Psychiatric Association is offering a number of free online assessment measures to monitor treatment progress and outcomes and enhance clinical decision-making. Click here for a list of available measures. Additional measures can be found below:

 

Instrument: Description: Links:
Brief Psychiatric Rating Scale
(BPRS)
Consists of 24 symptom constructs, each rated on a 7-point scale of
severity ranging from 'not present' to 'extremely severe'.

Tool

Instructions for Use 

Threshold Assessment Grid (TAG) Brief assessment of severity of a patient’s mental health problems. Tool & Instructions for use
Center for Epidemiologic Studies
Depression Scale (CES-D)
Standardized outcome measure used in the assessment of
individuals with depression.

Tool & Instructions for use- Paper

Tool & Instruction for use- Electronic

 

Rating Scales can assess behavioral problem areas and assist in determining the need for further evaluation. Where necessary, Blue Cross of Idaho has obtained permission from copyright holders for use and distribution.

 

Instrument: Description: Links:
Adult ADHD Self-Report Scale
(ASRS-v1.1) Symptom Checklist
A tool to help screen for ADHD in adult patients. Tool & Instructions for use
SNAP-IV Teacher and Parent Rating
Scale
Rating scale which helps indicate presence of ADHD and
oppositional defiant disorder.

Tool

Instructions for Use 

Vanderbilt ADHD Diagnostic Parent
Rating Scale
Contains rating scales for behavioral symptoms and
impairment in academic performance.
Tool & Instructions for use
Vanderbilt ADHD Diagnostic
Teacher Rating Scale
Contains rating scales for behavioral symptoms and
impairment in academic performance.
Tool & Instructions for use