How to Write Meaningful Interpretive Summaries

1
How to Write Meaningful Interpretive Summaries

• A CDCMHC/Quality Improvement Dept. Version 7/04

2
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
  CMHCs 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.

3
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.

4
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

5
Contents of Interpretive Summary contd

• 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 persons
  course of treatment and clinical outcomes after
  discharge (i.e. recovery).
• GAF/Level of Functioning

6
Contents of Interpretive Summary contd

• 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.

7
Points to Remember

• Supports the Diagnostic Impression
• Leads to the Individual Treatment Plan
• Suggests Discharge Planning criteria
• A stand-alone document

8
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.

9
Example How to Write the Interpretive Summary
from the point of Client Admission

• 1. Intake Information-contd
• 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.

10
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?

11
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. Michaels
  worrying is probably coming from unresolved
  issues regarding his marital problems, his
  mothers 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.

12
Example How to Write the Interpretative Summary
from the point of Client Admission

• 3. Draft Interpretive Summary- contd.
• Diagnosis
• I - 300.00 Anxiety Disorder NOS
• II - none
• III - none
• IV - Problems with primary support group,
  occupational problem, legal problem
• V - 60

13
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

14
Items to Carry Over to ITP

• Example contd
• 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 mothers 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

15
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

16
(No Transcript)