The 12 Core Functions and Electronic Record Keeping
John W. Herdman, Ph D.
“Computerize all health records within five years. The quality of health care for all Americans gets a big boost and costs decline.”
– President Obama
The global criteria for the core function of Reports and Record Keeping are:
- Prepare reports and relevant records integrating available information to facilitate the continuum of care
- Chart relevant ongoing information pertaining to the client
- Utilize applicable information from written documents for client care
Many of you know my book Global Criteria: The 12 Core Functions of the Substance Abuse Counselor – Fifth Edition (www.johnherdman.com). You may not know that I am involved with a software development company called Eccentex that has created an electronic Case Management System called MyCaseRecords (www.mycaserecords.com). MyCaseRecords is the fastest growing case management solution for Substance Abuse and Mental Health Professionals.I’m involved because I can strategically see the time-savings and efficiency for front line counselors like myself and my clinic’s counselors. Parallels, my clinic in Lincoln, NE, has over 4000 clients now in the MyCaseRecords database. Information on these clients is available electronically 24/7 to my authorized users, i.e., counselors and staff. No longer are my counselors needing to enter repetitious client information. The forms in MyCaseRecords auto-populate all the repetitive fields from the client and case database. This makes the counselor’s job easier.
I have jokingly said over the years of training in the 12 core functions that the main reason people become substance abuse counselors is because they love to do paperwork. NOT! I’ve been a front-line psychologist, counselor and administrator for 36 years and MyCaseRecords makes my work so much easier and more enjoyable today.
Of the 12 core functions, the core function of Reports and Record Keeping is involved in all 11 of the other core functions – from Screening to Consultation.
Initial Screening data is electronically gathered and made available when a person becomes a client at Intake. A key component of MyCaseRecords is the scheduling function. Using the “New Schedule” option, a person can be quickly scheduled for an intake. Once the person becomes a client, the client is associated with a case (one client may have a number of cases or programs offered in an agency) and the scheduled intake creates pending forms needing to be completed by the counselor. At Parallels, any intake requires three forms – an Intake progress note that documents the forms and information necessary for client admission, both Intake forms and Orientation forms; a Clinical Staffing Form necessary for initial Consultation; and, a pending Treatment Plan form. These forms are listed as pending until completed by the counselor. This is helpful to the counselor and the program manager because the required paperwork is no longer lost or “forgotten”.
The next core function is Assessment. MyCaseRecords provides a comprehensive bio-psycho-social assessment including by not limited to alcohol and drug history. The Herdman Assessment Form, or HAF for short, was developed through my close partnership with Eccentex . I must say that I considered all of the information deemed important in a substance abuse assessment including the types of questions in the well-known Addiction Severity Index (ASI) and I wrote the logic for a narrative to save counselors time. In addition, the HAF provides optional tools, such as SASSI-3 where the counselor can enter the raw scores and the HAF calculates the T-Score and percentiles for the raw score and generates a narrative citing those scores that are significant. The HAF has the University of Rhode Island Change Assessment (URICA), a public domain scale to evaluate a client’s readiness for change. The HAF provides a table for ASAM Ratings in the six dimensions. A complete library of DSM-IVTR codes is provided to standardize the diagnoses and eliminate spelling errors. Although the HAF generates a very reader friendly narrative report, the counselor is still responsible for rating the client on the ASAM, deciding on an appropriate level of care, making an appropriate diagnosis, summarizing and making all recommendations for client care.
The Intake generates a Treatment Plan form that can be completed based on the Assessment and other information available about the client. Counselors complete treatment plans on clients. MyCaseRecords makes this process easier for the counselor while offering the capability of being individualized for each client.
Every individual or group Counseling session needs to be documented. MyCaseRecords has a Library of Forms, especially for progress notes, to fit most agencies’ needs. Some agencies use SOAP notes; others DAP or MAP notes. MyCaseRecords auto-populates the client data from the database, again eliminating repetitive data entry. The counselor still must type in the individual client progress.
The remaining core functions also require some sort of documentation. Case Management activities are documented on a Note or a Documentation Log. A Crisis Intervention is documented on a Progress Note and may necessitate a change in the Treatment Plan. Client Education is documented on a Documentation Log or a separate Group or other progress note. Referral and Consultation are documented for the records as required of your agency on either a Note or Documentation Log. At Parallels, I have an Initial, Intermediate, and Discharge Staffing Form. The Initial Staffing Form is generated at Intake; the Intermediate Staffing Form - either as needed, or every 30/60/90 days; and the Discharge Staffing - at the Discharge planning individual counseling session.
Working with MyCaseRecords is the first time I have become excited about the paperwork. How can MyCaseRecords help you?
- Access client information anytime, anywhere
- Keep secure and centralized client data
- Effortlessly manage your scheduling
- Improve your efficiency of operations using reports
- Focus more on clients instead of paperwork
MyCaseRecords is user-friendly. The program itself is loaded with help options. Most of the buttons and links are intuitive. The staff at Eccentex is very willing to assist you in eliminating your stresses about a new system or in using electronic records for the first time. MyCaseRecords is an easy solution for a solo practice, small group or larger agency. It can handle from 1 to thousands of users – all easily, efficiently and effectively. An agency or individual may also ask for the creation of their own forms to use with MyCaseRecords.
The cost per user is less than most counselors’ cell phone plans and the benefits are far more extensive. Each individual or agency has its unique needs and requirements, so please contact Eccentex to find out how affordable MyCaseRecords can be for you or your agency. Their phone number is 1-866-432-2368. You can test drive MyCaseRecords by signing up for a 30-Day Free Trial. Go to: www.mycaserecords.com. I hope you contact me or Eccentex if you have any questions. Look for training opportunities sponsored by Recovery Today.