Treatment and Progress Notes - Los Angeles County, California
Treatment and Progress Notes
For Social Workers, Marriage & Family Therapists, and Psychologists
(including students of these disciplines)
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Treatment Services
Purpose of Documentation
Progress Note Requirements
Examples
How to use IBHIS
LACDMH Quality Assurance Unit ¨C Policy and Technical Development Team ¨C 7/6/20
Standard Course of Action
1. Assessing
o
o
Complete a mental health assessment and establish medical
necessity;
Complete an initial medication evaluation (if needed)
2. Planning
o
Develop a client treatment plan (and if applicable, obtain medication
consent) with the client; then
3. Treating
o
Provide treatment services to address the identified mental health
condition and assist the client in reaching his/her objectives.
What are Treatment
Services?
Treatment Services
Treatment Services = services that address a client¡¯s mental
health needs and are not primarily for the purpose of:
o
o
o
o
Assessment
Plan Development
Crisis Intervention
Linkage and referral if a need of immediate concern exists
? Documented in
the client¡¯s
Treatment Plan
? Provided to the
client or the
significant
support person
? Provided
individually or in a
group/family
setting
? Provided in
person, over the
phone, or via
telehealth
For more information, refer to the Organizational Providers Manual
Treatment Services
For treatment services to be reimbursable by Medi-Cal, the
interventions described must:
?
Represent a covered Specialty
Mental Health Service (service
component)
Mental Health
Services (MHS)
?
?
?
?
?
?
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Reduce the client¡¯s impairment,
restore his/her functioning, or
prevent significant deterioration in
the client¡¯s functioning
?
Be on the client¡¯s treatment plan
Assessment
Plan Development
Therapy
Rehabilitation
Collateral
Be individualized to the client¡¯s
specific needs and relate to the
client¡¯s diagnosis and impairments
For more information, refer to the Organizational Providers Manual and QA Bulletin 17-13
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