CLINICAL DOCUMENTATION GUIDE - Health, Well-being & Safety
CLINICAL DOCUMENTATION
GUIDE
2020
Version 2.0 Updated included diagnoses
BEHAVIORAL HEALTH AND RECOVERY SERVICES BHRS Documentation Manual v 8/25/2020
CONTENTS
1
INTRODUCTION/COMPLIANCE
1.1
Why Do We Have This Manual?
5
1.2
Compliance
6
2
GENERAL PRINCIPLES OF DOCUMENTATION AND AUTHORIZATION TIMEFRAMES
7
2.1
General Principles of Documentation
7
2.2
Signatures
8
2.3
Establishment of Service Authorization Period
9
2.4
Timeframes for Submission of Documentation for Service Authorization Admission 10
3
ESTABLISHMENT OF MEDICAL NECESSITY
13
3.1
Assessment
13
3.2
Medical Necessity
15
3.3
Components of Medical Necessity
16
3.3.1
Diagnostic Criteria
16
3.3.2
Impairment Criteria
17
3.3.3
Intervention Related Criteria
16
4
TREATMENT PLANNING
18
4.1
Client Plan
18
4.1.1
Client Participation and Signatures
19
4.1.2
Timeliness of Client Plans
19
4.1.3
Revisions to The Plan
20
4.2
Components of The Client Plan
20
4.2.1
Client Plan Dates
21
4.2.2
Client's Goals
21
4.2.3
Client Strengths
22
4.2.4
Obstacles to Achieving Goals
22
4.2.5
Objectives
23
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4.2.6
Interventions
24
5
PROGRESS NOTES
26
5.1
Progress Note Format (SIRP)
27
5.2
Timeliness of Documentation of Services
29
5.3
Finalizing a Progress Note
29
6
SPECIALTY MENTAL HEALTH SERVICES
30
6.1
Descriptions of Mental Health Service Procedures
30
6.1.1
Assessment
30
6.1.2
Plan Development
30
6.1.3
Rehabilitation
31
6.1.4
Individual Therapy
31
6.1.5
Family Therapy
32
6.1.6
Group Therapy
32
6.1.7
Collateral
32
6.1.8
Medication Support
33
6.1.9
Brokerage
33
6.1.10
Crisis Intervention
34
6.2
Non-Billable Services
35
6.3
Lockouts and Limitations
37
6.4
Service Type Comparison
38
6.4.1
Combining Multiple Service Types
39
6.5
Case Conferences
39
7
SCOPE OF PRACTICE/COMPETENCE/WORK
40
7.1
Behavioral Health Professional Classifications and Licenses
41
7.2
Who Can Provide What Procedure
44
7.3
Utilization Review
45
8
INFORMED CONSENT
46
8.1
Minor Consent
46
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8.2
Medication Consent
49
8.3
Authorization to Exchange PHI
49
9
DOCUMENTATION REQUIREMENTS FOR SPECIFIC PROGRAM TYPES
51
9.1
Medication Clinic Documentation
51
9.2
Full-Service Partnership (FSP) Documentation
53
10
SPECIAL POPULATIONS
54
10.1
Katie A. Subclass
54
10.2
Therapeutic Behavioral Services (TBS) Class
55
11
EXAMPLES
58
11.1
Examples of Strengths
58
11.2
Examples Of "Intervention Words"
58
11.3
Examples Of "Interventions" For Specific Psychiatric Symptoms
59
11.4
Examples of Progress Notes
63
APPENDICES
A
Glossary
B
Covered DSM-5 Diagnoses for Outpatient Services
C
Title 9 service definitions
D
Coordinated care plan (C.P.) guideline
E
BHRS Checklist for Documentation
F
Abbreviations
G
Lockout Assistant
H
BHRS-25 Documentation Standards Policy
I
List of revisions in the 2020 Edition
BHRS Documentation Manual v 8/25/2020
4
Chapter 1. INTRODUCTION/COMPLIANCE
1.1. WHY DO WE HAVE THIS MANUAL?
As a behavioral health system, The Marin Behavioral Health and Recovery Services (BHRS) is committed to delivering client and family driven care. It is important that our service providers understand and embrace this philosophy. Client centered care has been recognized as a best practice in behavioral health. "All services and programs designed for persons with mental disabilities should be consumer centered, in recognition of varying individual goals, diverse needs, concerns, strengths, motivations, and disabilities." Client centered care involves putting the consumer in the driver's seat of the care they are receiving.
There's a saying throughout the healthcare industry that "if it isn't documented, it didn't happen." In order to give evidence that the services that BHRS provides reflect the values stated above, good documentation practices need to be followed. This manual has been developed as a resource for providers of BHRS. It outlines documentation standards and practices required within the Children, Youth and Family System of Care, Adult/Older Adult System of Care, contract providers, and Substance Use Services. It serves to ensure that providers within BHRS meet regulatory and compliance standards of competency, accuracy, and integrity in the provision and documentation of their services.
While this manual is not specific to any particular electronic medical record system, there are many specific items that refer to Clinician's Gateway (CG). Where this is the case, it is usually stated as "In CG..."
As with any manual that incorporates policies and regulations, updates will need to be made as these policies and regulations change. When updates are distributed, please be sure to replace copies or sections that have been downloaded or printed.
Please note that this is primarily a CLINICAL documentation guide, i.e., the main focus through this manual is the clinical documentation in the medical record. There are other required documents which are more administrative. These are included in Appendix E.
Sources of Information
This Clinical Documentation Guide is to be used as a reference guide and is not a definitive single source of information regarding chart documentation requirements. This manual includes information based on the following sources: Code of Federal Regulations (CFR) 45 and 42, the California Code of Regulations (CCR) Title 9, the California Department of Health Care Services' (DHCS) Letters and Information Notices, American Health Information Management Association (AHIMA), the Marin County Behavioral Health and Recovery Services (BHRS) policies & procedures, directives, and memos; and the Quality Improvement Program's interpretation and determination of documentation standards. Note that many policies may be titled under BHRS' previous name, MHSUS. As policies are updated or revised, they will be renamed BHRS policies.
Suggestions and Feedback
Suggestions and feedback for enhancements, improvements, or clarifications to this manual are welcome. Please submit by using the BHRS Clinical Documentation Guide Feedback Form or by emailing Quality Improvement.
BHRS Documentation Manual v 8/25/2020
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