Documentation at Dawn Farm

(AKA - Paperwork at Dawn Farm)

Staff Related Documentation

Time Sheets

These are to be filled out by any hourly employee. They include all hours worked up to and including the Friday prior to payday. Time sheets are completed electronically via Nova Time.

Time-Off Request

These are to be filled out by each staff member before they use any vacation, personal or compensatory time. They are to be filled out immediately upon returning after using any sick time. The form is given to the staff’s supervisor who then gives it to the Finance Coordinator.

Expense Form

To be filled out in order to be reimbursed for mileage and any money spent for the Farm. For anything other than mileage, a receipt must be included. This should be given to supervisor for approval and then forwarded to the Finance Coordinator for payment. All facilities use the same form.

Check Request Form

This form must be filled out by a staff person with supporting documentation prior to the issuance of any check for petty cash, conference fees, etc.

Incident Reports

Incident reports are filled out by on duty staff to document any critical incidents, including, but not limited to, injuries, illnesses, altercations with or between residents, major rule violations, or any allegation of abuse or neglect. Incidents are now filled out online through Apricot. Once filled out, supervisors review it and make recommendations. The President, Clinical Director, and Project Manager also review records and make recommendations as needed. Paper copies are still kept in the main office of each facility. A review of all incident reports, along with recommendations, will be presented by the Project Manager at each QA meeting.

Client Related Documentation

Daybook

There is a Daybook at the Farm, Dawn Farm Downtown and Spera. It is the most basic form of documentation and communication at Dawn Farm. Recorded in it are the names of on-duty staff, admissions, discharges, census, names of those normally scheduled staff who are not in, salient events, appointments, and messages. Please read at the beginning of each shift and record all pertinent data. Requests for staff to do drills are also put in the daybook. Daybooks are kept in the main office of each facility, except for at the Farm. The Farm's Daybook is located in the staff kitchen.

Medication Sheets

For each medication prescribed, the staff on duty fills out a medication sheet when the medication reaches the facility. Information on sheet includes name of client, name of medication, dosage, times to be administered. On-duty staff is to announce medication times and sign-off on medication sheet as each medication is dispensed. At Spera, both staff and clients initial medication sheet.

Incident Reports

Episode Intake

This form is in Apricot and collects client information that is common to the intake process in all programs using Apricot. It includes information on demographics, family, drug use history, legal status, medical status, socio-economic status and a mental status screen. To be printed and placed in the Intake section of case file.

Prescreen/Intake Team Screening

This form is in Apricot and collects client information to determine the most appropriate program referral at that time. It includes information on demographics, drug use history, legal status, medical status, and socio-economic status.

Residential Case File

Residential Intake Form

This form is in Apricot and collects initial diagnostic impression, anticipated length of stay, client’s perceptions of their strengths, needs and preferences and an initial assessment. Completed by the intake interviewer. To be printed and placed in the Intake section of case file.

Casefile Checklist

The primary therapist assigned to each client must initial and date a checklist of information pertaining to the client’s case when each task is completed.

Releases

At intake, the client is given a copy of Dawn Farm Rules and Regulations, Know Your Rights, Confidentiality of Alcohol and Drug Abuse Patient Records, Dawn Farm Statement of Client Rights, Dawn Farm Resident Grievance Procedure, Dawn Farm Statement of Ethics for Clients and Safety Procedures to read. They are then given a packet of releases to read and sign. A staff member is always present to answer questions and witness the signatures. The releases include: permission to communicate with DHS, Consent for Treatment, acknowledgment of understanding of Recipient Rights and the identity of Recipient Rights Advisor, acknowledgment of restrictions DF routinely places on above rights, acknowledgment of receipt and understanding of Rules and Regulations, acknowledgment of understanding of storage of belongings, acknowledgment of receipt and understanding of Confidentiality Policy, acknowledgment of receipt and understanding of Safety Procedures, acknowledgment of understanding of Discharge Policy, Release for Follow-up Contact, permission to include residents in group tours of DF, permission for DF to talk to friends and family members designated by client, permission to maintain contact with criminal justice system on client’s behalf, a release allowing former treatment centers to share their records with DF. To be placed in the Releases section of the case file

Admission and Discharge Data Forms

The intake interviewer fills out admission data form for each new client in Apricot. The Primary Therapist completes Discharge Summary within two weeks of a clients discharge.

Treatment Goals

This form is part of the intake packet and allows the clients to check off goals they may have as they enter the program. This is used to formulate recovery plans and to guide the entire treatment.

Progress Notes

The Progress Notes are a log of all progress in treatment and practical steps taken on behalf of client. This includes group notes, pertinent contact with client outside of group, decisions re: client made in staff meeting or with your supervisor, medical interventions, appointments, phone calls made for client, contacts with legal system, phase changes, etc. All entries should be signed by staff, including credentials, and completed within 24 hours of one of the previously mentioned occurrences. Progress Notes are completed electronically in Apricot. The Group Notes and Case Notes are kept in separate binders which is kept in the office to which all therapists have access. The Primary Therapist is responsible for ensuring transfer to case file.

Health History And Physical Exam

At the Farm: This form is filled out by the client at intake. A copy is placed in the medical section of the case file, along with a copy of client's picture ID and health insurance card (when available) and a copy is sent to the Packard Health where the client receives an initial physical within one week of admission. After the doctor performs the physical exam, medical dictations are provided to the Primary Therapist and the Primary Therapist is responsible for placing them in the medical section of client’s case file.

At DFD: Within one week admission, clients receive an initial physical at Packard Health Clinic. They complete a Health History at the clinic prior to the physical exam. A copy of the Health History is provided to the Primary Therapist who places in the medical section of the client's file.

Client Questionnaire

Form to be filled out by client within one week of admission. Primary Therapist reviews the form with client during the client interview within one week of admission. Forms the basis of Psycho-social Assessment. To be placed in Assessment section of case file.

Psycho-Social Assessment

Form on computer which allows primary therapist to assess pertinent areas of the client’s life and their impact on treatment planning. Also included is the Interpretive Summary which includes the counselor’s synthesis of the implications for treatment of all the data collected. lt is the “so what?” portion of the Psycho-social Assessment and should only be a paragraph. This form must be completed within 14 days of admission, be signed by staff and supervisor and be placed in the Assessment section of the case file.

Legal System Contact

Within two business days of admission, the Primary Therapist contacts (via phone or letter) each lawyer, P.O., etc., letting them know that the client is in treatment and giving basic information about the program. The primary therapist then maintains contact with the Legal system per the client's request. (They also have the option of having the client send in monthly reports themselves.) After discharge the legal system is notified by letter or phone immediately. If requested, the Primary sends a copy of the Discharge Summary within two weeks of discharge. To be placed in the legal section of the case file.

Individual Recovery Plans

These are individualized plans, with goals and measurable steps to be taken to reach the goals. They are based on the Treatment Goals, the Resident Input for Individual Recovery Plan form and discussion with the client and other staff. They are signed by the client, therapist and supervisor and the client is given a copy to refer to. The therapist’s copy is to be placed in the Treatment Plan section of the case file. Primary Therapist meet with their group of clients on a weekly basis to review progress on IRPs. At this time, new IRPs are developed and those completed are checked off.

Treatment Guide

This is given with the client binder or at phase change and is meant to give residents an idea of what it expected of them in order to move through each phase of treatment.

Aftercare Plan

When a client leaves treatment (either prematurely or after Phase 3), the Primary Therapist or Aftercare therapist and client agree on guidelines for them to follow after treatment. The areas addressed usually include living arrangements, AA meetings, sponsor/supports, employment, further treatment, etc. Both the client and the staff member sign the form and a copy is given to the client. It is then attached to the back of the Aftercare Discharge Summary or the Discharge Summary.

Releases

Upon entering Aftercare Group the client will need to renew any releases information that are needed during aftercare (e.g. permission to communicate with the criminal justice system, permission to talk to family members, etc.). To be placed in the Releases section of the case file.

Residential Discharge Summary

This is part of the residential intake form on Apricot. A Discharge Summary is to be written by the primary therapist within two weeks of each client’s discharge. There is a prototype of this form in each therapist’s computer file. When a client is moving into Aftercare Group, this should be noted. The Summary includes reason for discharge, diagnosis, initial assessment, initial expectations and desired outcomes, services provided, achievement of goals, final assessment and aftercare plan and needed referrals. A copy of the Aftercare Plan should be attached when applicable. When client records are requested, it is this form that will be sent. It is to be signed by the therapist and supervisor and a copy is placed in the client’s file in the Assessment section.

Aftercare Summary

Within two weeks of discharge from Aftercare Group, the Aftercare Therapist will complete the Aftercare Group Discharge Form found in Apricot. It is to be signed by the Aftercare Therapist and placed in the assessment section of case file.

Residential Program Evaluation and Client Satisfaction

Intake Data

At intake, clients are asked how many of the last 30 days they have: 1) used drugs or alcohol, 2) attended AA or NA, 3) been in jail, 4) been employed, 5) been in school, 6) received assistance from DHS.

Follow-Up

72 hours and one year after discharge, clients are contacted by phone and asked the same set of questions as at intake. This follow-up also serves as an opportunity to see if client needs further assistance and to gather client satisfaction data (see below).

Client Satisfaction Forms

Client satisfaction is measured three to five times: At intake and Discharge, monthly. The Intake form is part of the intake package, on duty staff is responsible for giving any client leaving treatment a Discharge Client Satisfaction Form and the follow-up form is completed as part of program evaluation (see above).

Outpatient Program

Schedule Book

The schedule book contains all client appointments, their phone number, and any other important identifying information that is deemed important (i.e. – referral source etc.)

Group Roster

All groups have a sign in sheet that all clients must sign when they attend any group. These rosters are used to indicate that the client was here for the service. It can be found in the corresponding binder, on the bookshelf in the main office. Each group has its own binder, which is divided by month.

Payment

A Payment form will be placed in the corresponding binder indicating which group the client will be attending. On this form a total balance and running balance will be kept. When a client pays for any services the counselor must take make a copy of the payment form and the sign in sheet (group roster) and place the money inside of the form indicating that the client was here for the services being charged. Then the counselor must place the money in an envelope, tally the total, and initial and date the envelope. Another counselor and/or supervisor must also sign off on the envelope after checking that the amount is correct.

Outpatient Case File:

Intake Form

Form used to gather demographic, background and mental status information during the intake interview. Completed by the intake interviewer. To be placed in the Intake section of case file.

Initial Progress Note

A summary of the intake information gathered, written by the intake interviewer. To be placed in the assessment section of case file.

Releases

At intake, the client is given a copy of Dawn Farm Rules and Regulations, Know Your Rights, Confidentiality of Alcohol and Drug Abuse Patient Records, Dawn Farm Statement of Client Rights, Dawn Farm Resident Grievance Procedure, Dawn Farm Statement of Ethics for Clients and Safety Procedures to read. They are then given a packet of releases to read and sign. A staff member is always present to answer questions and witness the signatures. The releases include: Consent for Treatment, acknowledgment of understanding of Recipient Rights and the identity of Recipient Rights Advisor, acknowledgment of restrictions DF routinely places on above rights, acknowledgment of receipt and understanding of Rules and Regulations, acknowledgment of understanding of storage of belongings, acknowledgment of receipt and understanding of Confidentiality Policy, acknowledgment of receipt and understanding of Safety Procedures, acknowledgment of understanding of Discharge Policy, Release for Follow-up Contact, permission for DF to talk to friends and family members designated by client, permission to maintain contact with criminal justice system on client’s behalf, a release allowing former treatment centers to share their records with DF. To be placed in the Releases section of the case file.

Progress Notes

Group Notes

The group leader details each client’s participation after each group session. After each group session the group notes are placed in the client file.

Individual Therapy Notes

If a client is doing individual therapy as a part of their treatment, then an individual therapy note will be placed under the common progress note in the file. This will document the content of the session, any new goals, or issues that stood out in the session, and progress that was made in the session. It may also document concerns, clinical assessment and recommendation by the therapist. It will be initialed with the therapist’s credentials at the end of the note.

Referral

If a client is found to need a referral for more treatment, help with another issue, etc. then a letter is created with information about where in the county the client could go to address these issues. Trying to find a good fit between the clients needs and services offered is always the primary goal.

Client Questionnaire

Form to be filled out by client within one week of admission. It is generally mailed to the client with a pamphlet describing our services and an initial contact letter to the client. Primary counselor reviews information with client within two weeks of admission. Forms the basis of Psycho-social Assessment. To be placed in Assessment section of case file.

Psycho-Social Assessment

Form on computer, which allows primary therapist to assess pertinent areas of the client’s life and their impact on treatment planning. Also included is the Interpretive Summary, which includes the counselor’s synthesis of the implications for treatment of all the data collected. lt is the “so what?” portion of the Psycho-social Assessment and should only be a paragraph. This form must be completed within 45 days, be signed by staff and supervisor and be placed in the Assessment section of the case file.

Legal System Contact

Within the first week of treatment, the admitting therapist calls each lawyer, P.O., etc., letting them know that the client is in treatment and giving basic information about the program. If required, the therapist will send a letter as well. The primary therapist then maintains contact on a monthly basis. (They also have the option of having the client send in monthly reports themselves.) After discharge the legal system is notified immediately. If requested, the Primary sends a copy of the Discharge Summary within two weeks of discharge. To be placed in the legal section of the case file.

Individual Treatment Plans

These are individualized plans, with goals and measurable steps to be taken to reach the goals. They are based on Treatment Goals or needs identified by the client during the initial intake. The therapist’s copy is to be placed in the Treatment Plan section of the case file. The client receives a treatment plan review about four weeks after they start their session here. During this time, the counselor reviews the initial goals that were set to see what goals have been met, not met, and what new goals the client will work on during the last part of their treatment. They are also given an Aftercare Plan at discharge.

Aftercare Plan

When a client leaves treatment, the primary therapist and client agree on guidelines for them to follow after treatment. The areas addressed usually include, AA meetings, sponsor/supports, employment, further treatment, etc. Both the client and the staff member sign the form and a copy is given to the client. It is then attached to the back of the Discharge Summary.

Outpatient Discharge Summary

A discharge summary is to be written by the primary therapist within two weeks of each client’s discharge. There is a prototype of this form in each therapist’s computer file. The Summary includes reason for discharge, diagnosis, initial assessment, initial expectations and desired outcomes, services provided, achievement of goals, final assessment and aftercare plan and needed referrals. A copy of the Aftercare Plan should be attached when applicable. When client records are requested, it is this form that will be sent. It is to be signed by the therapist and supervisor and a copy is placed in the client’s file in the Assessment section.

Outpatient Program Evaluation And Client Satisfaction

Intake Data

At intake, clients are asked how many of the last 30 days they have I) used drugs or alcohol, 2) attended AA or NA, 3) been in jail, 4) been employed, 5) been in school, 6) received assistance from DHS.

Follow-Up

Client Satisfaction Forms

Client satisfaction is measured three times. The Intake form is part of the intake package, on duty staff is responsible for giving any client leaving treatment a Discharge Client Satisfaction Form and the follow-up form is completed as part of program evaluation (see above).

Spera

Medication Sheets

The intake counselor charts each medication prescribed on the Medication Sheet. Both prescription and over the counter medications are recorded on this form. Information included on the form is: client name, medication name, dosage, and administration times. The medication sheet remains in the clients file. Spera staff and client initial each administration times. Upon discharge, client signature and date added to form, indicating medications were returned.

Client Roster

All incoming clients are logged by on-duty staff. This includes client name, number, age, sex, race, primary drug, number of previous treatments, county of residence, admission date and time, discharge date and time.

Personal Belongings

On-duty staff logs all belongings stored for client at intake and all belongings returned to client upon discharge. The form is kept in the client’s file.

Spera Case File:

Initial Spera Intake

Filled out by on-duty staff at intake. Includes demographic and background data, current medical state, medical history and drug use history. Once intake is complete, they are given a list of Detox activities, an AA support list to gather phone numbers while in Detox, meeting schedule, and Client Guidelines.

Client Vitals

The primary survey of client’s vitals signs is done at intake. Vitals are taken from all clients every 2 hours for the first 24 hours. If vitals are outside of guidelines after first 24 hours, staff will continue to check and document vitals until they are within safe guidelines and refer to medical director for next steps as needed.

Progress Notes

On-duty staff uses this form to record all pertinent information regarding a client. This includes their medical status, behavior, calls made on their behalf, referrals and issues that need to be dealt with by the next shift. All entries must have date, time and initials of staff.

Client Consent Form

At intake the client is given a Recipient Rights pamphlet, a copy of the Dawn Farm Confidentiality Policy and a Consent Form. These detail their rights and Dawn Farm requirements of them. All their questions are answered and they sign the form indicating that they understand these rights and requirements. On duty staff signs this form as well. It is kept in the client file. If the client has impaired thinking at intake, the forms are reviewed after 24 hours and resigned.

Recovery Plan

Each client is given a recovery plan while at Detox. It is developed during the first referral session. It details the services that will be offered to the client. It is signed and dated by the client and counselor. A copy is also given to the client.

Physical Examination Report

All clients receive a physical assessment by the Dawn Farm doctor/nurse during their stay, based on triage classification.

CMHPSM Admission And Discharge Forms

On duty staff fills out appropriate forms via CRCT at admission.

Discharge Summary

This is completed by on duty staff upon client’s discharge. It includes basic data on the client and a brief summary of client’s stay in detox. Also included are the referrals made and aftercare recommendations. This is signed by the staff person and the Detox Coordinator.

Aftercare Plan/ 72 Hour Follow Up

This form is filled out by client and on duty staff at discharge. It includes referrals and recommendations that are gleaned from the combined goals of staff and client. It also gives Dawn Farm permission to contact the client at any phone number(s) they provide us to gather follow-up data. A copy is given to the client and a copy is put in the follow-up notebook.

Client Satisfaction Questionnaire

The client fills this form out at discharge. On duty staff enter data in Apricot. A quarterly report will be presented to the Project Manager.

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