PART I - Department of Behavioral Health and Developmental ...

COMMUNITY SERVICE STANDARDS FOR ALL PROVIDERSSECTION III: DOCUMENTATION REQUIREMENTS1. OVERVIEW OF DOCUMENTATIONThe individual’s record is a legal document that is current, comprehensive and includes those persons who are assessed,served, supported, or treated. There are three core components of consumer related documentation. These include assessmentand reassessment; treatment planning; and progress notes. These core components are independent and yet must be interrelatedin order to create a sound medical record. The documentation guidelines outlined herein do not supersede servicespecificrequirements. This Provider Manual may list additional requirements and standards which are service-specific; whenthere is a conflict, providers must defer to those requirements which are most stringent.A. Information in the record must be:i. Organized, Complete, Current, Meaningful, and Succinct;ii. Written in black or blue ink (red ink may be used to denote allergies or precautions);B. All medical record documentation shall include the practitioner’s printed name as listed on his or her practitioner’slicense 3 .C. At a minimum, the individual's information shall include:i. The name of the individual, precautions, allergies (or no known allergies - NKA) and “volume #x of #y” on thefront of the record. Note that the individual's name, allergies and precautions must also be flagged on themedication administration record;ii. Individual's identification and emergency contact information;iii. Medical necessity of the service is supported;iv. Financial and insurance information necessary for adherence to Policy 6204-101;v. Rights, consent and legal information including but not limited to:1. Consent for service;2. Release of information documentation;3. Any psychiatric or other advanced directive;4. Legal documentation establishing guardianship;5. Evidence that individual rights are reviewed at least one time a year;6. Evidence that individual responsibilities are reviewed at least one time a year; and7. Legal status as it relates to Title 37.vi. Pertinent medical information;vii. Records or reports from previous or other current providers;viii. Correspondence.ix. Frequency and style of documentation are appropriate to the frequency and intensity of services, supports,and treatment and in accordance with the Service Guidelinex. Clear evidence that the services billed are the services provided.xi. Documentation includes record of contacts with persons involved in other aspects of the individual’s care,including but not limited to internal or external referrals.xii. There is a process for ongoing communication between staff members working with the same individuals indifferent programs, activities, schedules or shifts.2. ASSESSMENTIndividualized services, supports, care and treatment determinations are made on the basis of an assessment of needs with theindividual. The individual must be informed of the findings of the assessments in a language he or she can understand.A. Assessments must include but are not limited to the following:i. Justification of elements which support diagnosis;ii. Summary of central themes of presenting symptoms/needs and precipitating factors;iii. Consumer strengths, needs, abilities, and preferences;iv. Individual’s hopes and dreams, or personal life goals;v. Individual’s Perception of the issue(s) of concern;vi. Prior treatment and rehabilitation services used and outcomes of these services;vii. Interrelationship of history and assessments;viii. Preferences for treatment, consumer choice and hopes for recovery;3It is acceptable that the initials can be used for first and middle names. The last name must be spelled out and each of these must correlatewith the names on the license. This is an effort to ensure that a connection can be made between the printed/stamped name on the chart entryand a license.FY2013 Provider Manual for Community Behavioral Health Providers Page 169