VI.B GENERAL CLINICAL POLICIES FOR INTERNS AND POSTDOCTORAL FELLOWS

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Fri, 06/05/2015
Revised: 
Fri, 06/05/2015
Policy: 

Clinical Services:

A.    Scheduling appointments:

First appointments (intakes) are scheduled by the front office staff or phone triage staff.  Each intern and postdoctoral fellow will provide 2-3 timeslots for intake appointments each week.  These timeslots will stay the same during the quarter, but can be changed from quarter to quarter if preferred.  Follow-up counseling sessions are scheduled by each CAPS staff member, including interns and fellows, into their electronic health record schedule.

CAPS doctoral interns amd postdoctoral fellows must keep their scheduled counseling appointments with clients unless otherwise arranged.  If an intern or fellow is ill or has an important personal matter that requires canceling a counseling appointment, every effort should be made to notify the client beforehand and reschedule the appointment.  If it is not possible to notify the client in advance, the intern or fellow can ask the Central Office staff to notify the client that the appointment is cancelled.  It is the responsibility of the CAPS intern or fellow to make every effort to reschedule the appointment as soon as possible

B.     Emergency Clinical Consultation:

When providing counseling to clients in your office, there may be times you will need immediate crisis consultation.  Please use the following order to seek consultation from a senior staff member:

A.    Appropriate Supervisor (primary or secondary)

B.     Any backup management team member

C.     Staff on Crisis Services for the day

C.    Consultation When Conducting Crisis Services in Central Office for Doctoral Interns:

When interns are conducting their crisis services shift, they work closely with a senior staff member.  The senior staff member who is paired with the intern on crisis services will provide consultation and assistance to the intern during their shift.  Each quarter a schedule is developed with assigned crisis staff.  When you need consultation during your crisis services shift, please use the following order for consultation:

A.    Crisis staff paired with intern

B.     CAPS Management team member

C.     Call Central Office for assistance in locating an available staff member

D.    Criteria for Consultation when on Crisis Duty for Interns and Postdoctoral fellows:

Please seek consultation at any time when you are on crisis duty by consulting with your crisis team member. We utilize a team approach when conducting crisis intervention at CAPS.  We would rather you consult more than less in order to get assistance for safety and risk assessment, referral resources, and complex decisions.

i.      Always consult in the following situations:

1)      Safety issues with client - moderate or high risk clients, which can include:

a.       Danger to self, danger to others, or gravely disabled; self harm behaviors.

b.      Severe substance use/abuse.

c.       Presence of any psychotic symptoms that impair judgment and functioning.

d.      Suicidal ideation without a plan, but has previous attempts, significant stressors.

2)      Decisions and procedures for voluntary and involuntary hospitalization.

3)      Medical issues present:  serious substance use/abuse, eating disorders, cutting or other self harm behaviors.

4)      Child abuse or Tarasoff reporting issues.

5)      If you need assistance about whether to refer to Psychiatry or the Health Center for a medication referral.

6)      Complicated presenting symptoms.

7)      Questions about minors.

8)      Any questions about referrals.

E.     Immediate Emergency Assistance:

A.    Use the panic button located in your office

B.     Dial 911

C.     Call Central office and say "Please cancel my appointment with Dr. Arnold".  The front office staff will ask if you need the police called, or need immediate consultation.  You may use this safety code if you feel you need immediate emergency assistance but do not think it is appropriate to verbalize that in front of the client.

F.     Hours for Providing Clinical Services

A.    Interns and fellows provide clinical services between the hours of 8:00 AM through 5:00 PM when CAPS staff are on campus.

B.     Interns and fellows do not provide clinical services after hours unless they are providing conjoint services with a senior staff member, such as co-facilitating a group.

C.     If a CAPS staff who co-facilitates a group during the day  (8-5 PM) with an intern will be absent, the following should occur:

·         Discuss with intern their readiness with facilitating the group on their own; and

·         The CAPS staff will contact a CAPS staff member to serve as backup for the intern; the backup person must be on campus and accessible (interruptible) during the group time period for the intern.

D.    If a CAPS staff member who co-facilitates a group after 5 PM with an intern will be absent, the group will have to be canceled.  Interns do not provide clinical services before 8 AM or after 5 PM without a senior clinical staff present.

E.     If an intern or fellow is out of the office, they must inform the Central Office to have their clinical appointments cancelled and rescheduled.

G.    Clinical Reports:

CAPS uses the electronic health record system, Point and Click (PnC), for all clinical documentation. All interns and fellows are required to complete clinical write-ups for each client, including intake reports, crisis assessments, case notes, group therapy notes, and termination reports by using the templates connected with each visit type listed above in PNC for clinical documentation.  All clinical documentation must be consistent with the Record Keeping Guidelines of the American Psychological Association (December 2007), which can be found in appendix Section XVIII.  Interns will receive training on utilizing PnC during orientation training and in individual and group supervision.

A.    Intake Reports:

CAPS uses the standard PnC template for client intake reports

B.     Case Notes:

Interns and fellows will consult with their supervisors regarding appropriate case note format to use in the basic PnC template for case notes. Most typically, interns utilize the SOAP format for writing case notes.

C.    Termination Reports:

CAPS uses a standard PnC template for client termination reports.

D.    Crisis Services Documentation:

CAPS uses a standard PnC template for crisis services documentation.

E.     Couples Notes:

CAPS uses a standard PnC template for couples clinical documentation.

H.    Informing Clients about Supervision and Confidentiality:

Consistent with the California State Board of Psychology regulations, supervisors must inform the intern's or postdoctoral fellow's clients about their status as supervisors.  This requirement is implemented by interns and postdoctoral fellows informing clients about their training status in CAPS in the first session.  Interns and fellows are required to give each client a "Supervisory Disclosure Form" (See Appendix D) and discuss with the client their training status and confidentiality, and provide the client with the name, license number, and phone number of their supervisor. The client signs the Supervisory Disclosure form, which is scanned into the client's PnC clinical file.

I.  Interns and postdoctoral fellows may work in their offices after 5 PM for general administrative tasks. 

J.  All  interns and postdoctoral fellows are expected to adhere to organizational policies, including state and federal guidelines such as The Health Insurance Portability and Accountability Act (HIPAA) and OSHA.  They participate in new employee orientation, which explains these guidelines.