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

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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.

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