How to Write Meaningful Interpretive Summaries by club56

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									How to Write Meaningful
Interpretive Summaries




 A CDCMHC/Quality Improvement Dept. Version 7/04
              Why this training?

   On 5/4/04 a CARF trainer noted that although
    Community Mental Health Centers have shown
    an improvement in this item, as of 2003, 20% of
    CMHC’s surveyed were still cited for their poor
    Interpretive Summaries.

   This on-line training, of 15 slides, which may be
    printed (in black/white option with 2-4 slides per
    page), has been developed to help clinicians
    improve their Interpretive Summaries.
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                 Definition
Interpretive Summary: a paragraph or paragraphs
  written by the staff member assigned to
  integrate and interpret, from a broader
  perspective, all history and assessment
  information collected (CARF, 2003).

 The Interpretive Summary should summarize
  the relevant information and stand alone as if
  there was no other information, forms or notes.


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Contents of Interpretive Summary: What to
   Use from Initial Clinical History and
                Evaluation
   Central theme(s) apparent in the presentation of
    the person served.

   Histories (family, cultural, marital, work) and
    assessments (medical, psychosocial, spiritual,
    vocational, etc.), with special emphasis on
    potential inter-relationships between sets of
    findings.

   Mental Status
                                                   4
    Contents of Interpretive Summary: cont’d
   The perception of the person served of his/her
    needs, strengths, stage of change, limitations,
    and problems.

   Clinical judgments regarding both positive and
    negative factors likely to affect the person’s
    course of treatment and clinical outcomes after
    discharge (i.e. recovery).

   GAF/Level of Functioning
                                                  5
     Contents of Interpretive Summary:
                   cont’d
   Recommended        treatments, including       any
    further/special assessments, tests, etc., as well
    as routine procedures (e.g. laboratory tests).

   A general discussion of the anticipated level of
    care, length and intensity of treatment, and
    expected focus (goals), with recommendations.




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              Points to Remember


   Supports the Diagnostic Impression

   Leads to the Individual Treatment Plan

   Suggests Discharge Planning criteria

   A stand-alone document


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  Example: How to Write the Interpretive
Summary from the point of Client Admission

1.       Intake Information:

     Twenty-seven year old Michael c/o becoming an
     excessive worrier a year ago.      He is a computer
     repairman and spends the majority of his day worrying
     about his work which lowers his productivity. Today,
     Michael showed no signs of being anxious or depressed.
     Michael has no AOD/medical problems and his last
     physical was a year ago.


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  Example: How to Write the Interpretive
Summary from the point of Client Admission


1.       Intake Information-cont’d:
     Family history indicates a great deal of marital conflict in
     both his parents’ as well as in his own 3 yr. marriage.
     Michael claims his parents’ marriage was maintained for
     the “sake of the children” and that he has bothersome
     memories from his childhood.             Michael reports
     experiencing a high level of distraction, irritation,
     restlessness, and being on edge which sometimes leaves
     him fatigued and mildly depressed.


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 Example: How to Write the Interpretative
Summary from the point of Client Admission

2. Questions to answer when writing Interpretive
  Summary:

     What is the course of the disorder?
     What stressors affect the disorder? How? What are
      the complications?
     What may interfere with TX?
     How is daily functioning affected?



                                                          10
 Example: How to Write the Interpretative
Summary from the point of Client Admission

3. Draft Interpretive Summary
   Michael (27) has become an excessive worrier over the
   past 6 months and the majority of his day is spent
   worrying which causes tension, high level of distraction,
   irritation, and restlessness. Being on edge sometimes
   leaves him fatigued and mildly depressed. Michael’s
   worrying is probably coming from unresolved issues
   regarding his marital problems, his mother’s death and
   legal issues resulting from overspending on friends in his
   desire to be accepted and have friends. Perhaps Michael
   is also processing normal daily happenings in negative
   ways. He desires treatment and appears to be in the
   Preparation stage of change.

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 Example: How to Write the Interpretative
Summary from the point of Client Admission

3. Draft Interpretive Summary- cont’d.

Diagnosis
I - 300.00 Anxiety Disorder NOS
II - none
III - none
IV - Problems with primary support group, occupational
   problem, legal problem
V - 60
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              Items to Carry Over to ITP


Example

   Strengths: desires Indiv. & Marital Tx, has a steady job

   Needs: increase self-esteem, improve independence,
    resolve bereavement issues

   Abilities: intelligent, computer skills

   Preferences: pm. appointment


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             Items to Carry Over to ITP
Example –cont’d
   Goals: “I want to feel better”, “I wanna stop worrying”,
    “I feel like a failure”, decrease anxiety/worrying,
    increase self-esteem/confidence, improve decision-
    making skills, practice positive thinking, grieve mother’s
    death, develop healthy social support network

   Services: Indiv. Tx, Marital Tx, Group Tx, PMA to rule
    out medication

   Outcome/Discharge Criteria: able to relax & manage
    stress, improved marital communication, improved self-
    esteem


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                    References

Migas, N. (2004, May). CARF 2004 Behavioral
  Health Standards Update. Presented at the
  South Carolina Department of Mental Health,
  Columbia, SC.
The Commission on the Accreditation of
  Rehabilitation Facilities (CARF). (2003). CARF
  Behavioral Health Manual, 2003. Tucson, AZ:
  CARF



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