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

iv. Legibility – All documentation that is handwritten must be readable, decipherable and easily discernible tothe all readers.v. Conciseness and clarity – Clear language, grammar, syntax, and sentence structure is used to describethe activity and related information.vi. Standardized format – Providers are expected to follow best practices and select a format or create aprescribed narrative that can be used consistently throughout their provider. Specific details regarding actualpractice should be described in providers’ policies, procedures, training manuals and/or documentationinstruction sheets. All formats require a clear match or link between the progress note, assessment andservice and planning data.vii. Security and confidentiality – All documentation is managed in such a manner to ensure consumerconfidentiality and security while providing access and availability as appropriate.viii.ix.Activities dated - Documentation specifies the date/time of service.Dated entries – All progress note entries are dated to reflect the date of signature of the individual providingthe service (this date may differ from the actual date of service). Dates written to indicate the date of asignature may only be dated by the signer. In electronic records, the date of entry must reflect the date thatthe secure electronic signature was entered. Back-dating and post-dating are not permitted.x. Duration of activities – Documentation of the duration must be noted for all services to include the numberof units, times, and dates. For those services in which the unit/rate is based on time (not percontact/encounter), documentation must include time-in and time-out for all services. This requirementapplies for both face-to-face and collateral contacts. Residential services are excluded from the dailynotation of time-in/time-out and must follow the specific guidelines outlined in each specific residential code.Further instruction related to Psychosocial Rehabilitation and Peer Supports services can be found in therespective Service Guidelines.xi.xii.xiii.xiv.Rounding of Units – Rounding of units is permitted when a service meeting the service definition isprovided in less time than the unit increment requirement. Each provider must have an internal policyregarding rounding of units. Regarding “rounding” of units, a unit may be billed for a service when an activitymeets the service definition of the service billed but does not meet the full time/unit requirement. In order tobill a unit of service, at least 50% of the time required per unit must be provided and documented by the“time-in, time-out” documentation. For example, a provider may bill a single 15 minute unit for a servicegreater or equal to 8 minutes and less than 23 minutes. If the duration of the service is greater than or equalto 23 minutes and less than 38 minutes, then 2 units may be billed. Providers must document roundingpractices in internal policy.Location of intervention – For those services which may be billed as either in or out-of clinic 8 , progressnotes shall reflect the location as either in-clinic or out-of-clinic (unless otherwise noted in Service Guideline).If the intervention is in-clinic, no further specificity is required. If an intervention is “out-of-clinic”, the notemust reflect the specific location of the intervention; this indication must be specific enough that it can begenerally understood where the service occurred (for example: “…at the individual’s home,” “…at the grocerystore”, etc.). Documenting that the service occurred “in the community” is not sufficient to describe thelocation.1. When services are provided to youth at or during school, documentation must indicate that theintervention is most effective when provided during school hours.Participation in intervention – Progress notes shall reflect all the participants in the treatment and/orsupport intervention (consumer, family, other natural supports, multi-disciplinary team members, etc.)Signature, Printed staff name, qualifications and/or title 9 – The writer of the documentation is designatedby name and credentials/qualifications and when required, degree and title. If an individual is a licensedpractitioner, the printed name must be the name listed on his or her practitioner’s license on all medicalrecord documentation 10 . An original signature is required. The printed name and qualifications and/or titlemay be recorded using a stamp or typed onto the document. Automated or electronic documentation mustinclude a secure electronic signature 11 .8Modifier U7 should be used to denote out of clinic services. Additional information related to use of this modifier can be found in Section I.9 See Standards for All Behavioral Health Providers, Part II for additional information regarding credentials.10It 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.11As defined in PART I POLICIES AND PROCEDURES FOR MEDICAID/PEACHCARE FOR KIDS, a Secure Electronic Signature means anelectronic or digital signature, symbol, or process associated with a document which is created, transmitted, received, or stored by electronicmeans which (1) requires the application of a security procedure; (2) capable of verification/authentication; (3) adopted by a party with theintent to be bound or to authenticate a record; (4) signed under penalty of perjury; (5) unique to the person using it; (6) under the sole control ofthe person using it; and (7) linked to data in such a manner that if the data is changed the electronic signature is invalidated.FY2013 Provider Manual for Community Behavioral Health Providers Page 174