Kaiser Documentation
Kaiser Documentation
Embedded Files
Kaiser Intake Documentation
Go to Lucet
Search patient by first or last name
Ensure that the Treatment Progress Indicator (TPI) has been completed
If listed as expired or abandoned, select “Add Assessment”
Select “Launch Onsite for Patient” for the client if the session has already begun
Go to the “Notes” tab of Lucet patient file
Select “Add Note”
Add Initial Evaluation - adult (18+) or child evaluation
If you receive this prompt, "It is recommended to have an existing assessment…”, it means the TPI has not been completed. Complete TPI before proceeding
Inform the client of consent to treatment
If the client is a minor, confirm the custody agreement and ensure the parent is aware that custody paperwork or signed consent of both parents will be needed before the next session to continue treatment.
Discuss Release of Information (ROI) for Kaiser
When clients complete their patient portal, they agree to terms of service, which includes our Notice of Privacy Practices, which includes the ROI for Kaiser
Provide the Medical Center Number for Kaiser Permanente that is located in the Therapist Guide under the Kaiser Training)
Complete Intake in its entirety
After submitting Kaiser intake on Lucet, download it onto the computer and upload it into the patient’s file of SC 2.0.
SC 2.0 Documentation for Kaiser Intake
You will upload into client file “Hidden from Patient” and name “Kaiser Intake”
2.0 Documentation
Select Progress Note Date
Select cogwheel at top right and select "Use Evaluation Template"
Subjective section - write at the top in bold KAISER INTAKE SEE DOCUMENTS TAB FOR KAISER INTAKE ASSESSMENT
Then remove template after Symptoms/Behaviors and Onset
Objective section: Keep words “Mental Status Exam” and remove template except for client location and emergency contact. Write “SEE DOCUMENTS TAB FOR KAISER INTAKE ASSESSMENT”
Complete the remainder of Evaluation Template
KP Adult 18+ Evaluation.pdfKP Child Evaluation.pdfKaiser Missed Evaluation Documentation
The provider will call the patient at the start time of appointment. If unable to connect, clinician will leave voicemail regarding intake appointment, and inform client they can call back until 15 minutes after session start to be seen on intake date.
If no contact is made, a second attempt should take place 2 business days after initial scheduled appointment. Clinician will remind client of intake appointment, ask if they would like to reschedule, and inform client of final attempt in next business day.
The third attempt should take place 3 business days after the initial scheduled appointment informing client the slot has been released and they need to contact Kaiser for therapy referral. All communication attempts should be documented in Lucet as freeform note and in SC 2.0 in patient invite comments.
After call notes have been created release pending appointment (or mark discharged from cases if 2.0 account was made) and add Lucet availability.
Freeform and Invite Comment Documentation Template
1st attempt: Clinician attempted to contact client on (Date) at (Time) for scheduled intake, (outcome) (left voicemail, could not leave voicemail, number disconnected etc.)
2nd attempt: Clinician attempted to contact client on (Date) at (Time) to attempt to reschedule intake (outcome)
Final attempt: Clinician attempted to contact client on (Date) at (Time) and was unable to connect. Clinician informed client that client would need to reach out to Kaiser for new referral.
Kaiser Safety Plan Documentation
Safety Plan Summary MUST be completed if the CSSR-S score is 3 or above.
Go to Lucet patient file
Select "Notes" tab of patient file
Select "Safety Plan Summary"
Complete with Patient
Submit and download onto computer.
Upload into SC 2.0 client file, under Documents tab and mark as "Visible to Patient"
KP Safety Plan.pdfKaiser Discharge Documentation
Discharge Summaries will be completed when client is transferred to another Sensible Care clinician or when a client has completed an episode of care
Go to Lucet
Search patient by first or last name
Select "Notes" tab of patient file
Select "Discharge Summary"
Note: The CPT code will be the code for the last session you had with client
Submit
Upload into SC 2.0 client file, under documents tab and mark as "Hidden From Patient"
KP Discharge Summary.pdfKaiser Freeform Documentation
Freeform notes are non-billable notes to indicate changes in treatment, documentation of communication with client, and transfer of care.
Since we do not document progress notes in Lucet, it gives Kaiser more information related to client's progress in treatment.
You must complete freeform notes for clients who do not attend initial scheduled intake appointment.
Kaiser requires a phone call at the day and time of intake session, 2 business days after intake session, and 3 business days after intake session all documented within Lucet file (and SC 2.0 as a patient note if portal has been created). Communication attempts prior to the scheduled session (although recommended) do not count toward Kaiser's three attempt policy.
Page updated
Report abuse