Clinical Collaboration With Therapists

Part of the process for the PRP program includes meeting monthly with your mentees' therapists to go over any progress or issues you've encountered throughout the month. Any contact you make should be documented as a contact note. You should provide this update to their respective therapists monthly. We have included the contact info for all of the clients' therapists under the contact info section of their patient profile on TherapyNotes.

All clinical collaboration encounters must "be substantive in nature and constitute more than mere incidental contact.”

• Notes in the medical record must show evidence of the exchange of relevant clinical and rehabilitation-related information that is focused on the individual's progress toward independent functioning.

• Coordination/collaboration encounters must be in the form of one contact note per encounter.

• Each encounter should clearly delineate the nature and extent of the contact to include the encounter date, mode of contact (in-person, video conference, telephone, e-mail), the identity of the individual(s) being contacted (with relevant titles and credentials), and should reflect the content of the exchange related to the Individual Rehabilitation Plan (IRP)]

To create a Contact Note:

• Click Patients > Patient Name > Documents tab

• Click the Create Note button

• From the list that appears, select Contact Note

The note header automatically fills in information for the client, the client's insurance, the date and time the note was written, and which staff member created the note. To edit information in the note header such as the Note Title or Date & Time, click anywhere on the note header or click Edit in the upper right corner.

Contacted Party

Click in the Name field to select from a list of the client's contacts. Your selection will autofill both the Name and Relationship to Patient fields.

Alternatively, enter a Name for a contact that is not included in the client's contacts. Click in the Relationship to Patient field to select from a list of common types of contacts.

Method of Communication

Select how you communicated with the contact. Multiple options may be selected to account for the full exchange with the contact.

Reason for Communication

Click in the Reason for Communication field to select from a list of common responses, or enter a custom reason.

Billing Information

Enter the total number of minutes you spent communicating with the contact across all of the communication methods indicated in the Method of Communication section. Please leave the "patient will be billed for this communication" box unchecked.

Communication Details

Enter any details related to the communication, including who contacted whom and what was accomplished through the communication.

Sign and Save

Once you have completed your Contact Note, select the Sign this Form checkbox to electronically sign the note. Select whether the note should be visible only to clinicians assigned to the client or to all users from the Note is visible to dropdown. Click the Create Note button.