CLINICAL RECORD DOCUMENTATION STANDARDS – ValueOptions works

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Policy Title: CLINICAL RECORD DOCUMENTATION STANDARDS  MENTAL HEALTH




           CLINICAL RECORD
       DOCUMENTATION STANDARDS
This policy section defines the procedures and minimum standards for
documentation of Medi-Cal/Medicare Specialty Mental Health Services at
any site providing those services within Alameda County Behavioral Health
Care Services and its Behavioral Health Plan's Provider Network.




Section 8, page 1             12-2010
Policy Title: CLINICAL RECORD DOCUMENTATION STANDARDS  MENTAL HEALTH


CONTENTS

       Mental Health Policy & Documentation Standards


POLICY STATEMENT: MENTAL HEALTH

       All service providers within the Alameda County Mental Health Services system shall
       follow the Clinical Record Documentation Standards Policy. This includes providers
       employed by BHCS and all contracted providers. Service providers may develop
       additional policies in order to adapt these standards to their specific needs. If variance
       from this policy is needed, approval must be obtained from the Quality Assurance
       Administrator.


PROCEDURE

       This Section of the Quality Assurance Manual contains information about basic required
       chart management, informing materials, and the minimum requirements for clinical
       documentation. Most requirements are for all types of providers, as indicated;
       differences and exceptions for certain types of providers are so noted.


TABLE OF CONTENTS                                                                          PAGE

Definitions of Commonly Used Terms                                                              4

General Management of Clinical Records                                                          5
      General Record Maintenance
      Record Storage
      Record Retention
      Record Destruction

Medical Necessity: Providing the Rationale for Services                                         6
      Relevance of Medical Necessity for Documentation
      Medical Necessity Determination

Clinical Documentation Standards for Specialty Mental Health Services                           8

       Signature Requirements                                                                   8

       1. Initial Assessments                                                                   9
                Timeliness & Frequency
                Minimum Requirements

       2. Client Plans                                                                         12
              Timeliness & Frequency
              Minimum Requirements

       3. Progress Notes                                                                       15


Section 8, page 2                        12-2010
Policy Title: CLINICAL RECORD DOCUMENTATION STANDARDS  MENTAL HEALTH


              Progress Notes vs. Psychotherapy/Process Notes
              Timeliness & Frequency
              Minimum Requirements
              Special Situations: Progress Note Documentation Requirements
                      Medicare Billable Services
                      Group Services
                      Crisis Services
                      Documenting Missed Appointments
                      Documenting Lockout Situations
                      Documenting the Creation of Clinical Documents

       4. Discharge/Termination/Transition Documentation                      20
              Timeliness
              Minimum Requirements

       5. Annual Community Functioning Evaluation or Equivalent               21
             Timeliness

       6. Therapeutic Behavioral Services (TBS) Documentation                 22
          BHCS Requirements (in addition to TBS Documentation Manual
          Requirements)


Staff Qualifications for Service Delivery and Documentation                   23
       Licensed Practitioner of the Healing Arts (LPHA)
       Waivered/Registered LPHA
       Graduate Student Intern/Trainee
       Mental Health Rehabilitation Specialist (MHRS)
       Adjunct Mental Health Staff & Other Staff Not Meeting Above Category
           Qualifications


Citations                                                                     27




Section 8, page 3                     12-2010
Policy Title: CLINICAL RECORD DOCUMENTATION STANDARDS  MENTAL HEALTH



                         Definitions of Commonly Used Terms


Specialty Mental Health Services: This is the broad umbrella of Medi-Cal services directed at
the mental health needs of Medi-Cal beneficiaries. Speciality Mental Health Services include
the smaller umbrella of Mental Health Services. (CCR09)
       Mental Health Services: Assessment, Plan Development, Psychotherapy,
       Rehabilitation, and Collateral. (CCR08)
       Medication Support
       Case Management/Brokerage
       Psychiatrist & Psychologist Services
       EPSDT Supplemental Specialty Mental Health Services
       Day Treatment Intensive & Day Treatment Rehabilitation
       Crisis Intervention
       Crisis Stabilization
       Adult Residential Treatment Services & Crisis Residential Treatment Services
       Psychiatric Inpatient Hospital Services, Psychiatric Health Facility Services (PHF), and
       Psychiatric Nursing Facility Services
   (Mental Health Rehabilitation Centers [MHRC's] follow the documentation standards
   established in the California Code of Regulations, Title 9, Chapter 3.5, Section 786.15.)
   (CCR02)



This Policy addresses the documentation standards for all Specialty Mental Health
Services except Psychiatric Inpatient, PHF and Nursing Facility Services.

Types of Providers: The type of provider contract determines the documentation standards
and method of claiming for reimbursement of services. Each provider's contract specifies which
specialty mental health services they may claim; not all provider contracts authorize claiming for
all possible services.
Level 1 Providers:
            County-operated service providers of outpatient services (includes BHCS-identified
            Brief Service Programs, e.g., Crisis, Assessment Only)
            Organizational providers of outpatient services
            Full Service Partnerships (FSP's)
Level 3 Providers:
            Provider Network (office-based individual clinicians)
            Community Based Organizations with fee-for-service contracts


A Word About Terminology: ACBHCS providers and administrative offices have the intention
to be inclusive in the language used to refer to beneficiaries of the Mental Health Plan (e.g.,
consumers, clients, families, children, youth, transition-age youth, etc.). Depending on the
language used, it is possible that some beneficiaries could feel excluded or secondary in
importance. While it is the goal of ACBHCS to honor each individual's desire to be identified as
they wish, this Section of the Quality Assurance Manual is bound by regulatory language that
uses "beneficiary" and "client" in reference to documentation standards. Therefore, in the
interest of clarity, inclusion, and consistency with regulatory language, all beneficiaries will be
referred to as "clients" in this Section.


Section 8, page 4                        12-2010
Policy Title: CLINICAL RECORD DOCUMENTATION STANDARDS  MENTAL HEALTH




                         General Management of Clinical Records
                              (CFR2) (CC1) (CC2) (HS1) (CalOHI1) (DMHcontract2) (CCR23)



                               Applies to All Provider Contracts

For the purposes of these documentation standards, charts containing documentation of mental
health services are referred to as Clinical Records or Records.

General Record Maintenance:
Per BHCS, the "best practices" outlined below should be followed:
      Records should be organized and divided into sections according to a consistent
      standard allowing for ease of location and referencing. (BHCSQA09)
      Records should be sequential and date ordered. (BHCSQA09)
      Records should be fastened together to avoid loss or being misplaced. No loose papers
      or sticky-sheets in the chart (may staple). (BHCSQA09)
      Progress Notes must be filed in clinical records. Psychotherapy notes (process notes)
      should be kept separately. (CalOHI1)
      All entries must be legible (including signatures). (See "Clinical Documentation
      Standards" section, "Signature Requirements.") (CCR30) (DMHcontract3)
      Use only ink (black or blue recommended). (BHCSQA09)
      Every page must have some form of client identification (name or identification number,
      etc.). (BHCSQA09)
      Do not use names of other clients in the record (may use initials or similar method of
      preserving other clients' identities). (BHCSQA09)
      Do not "rubber stamp" your record entries; tailor wording to the changing needs of each
      individual. (BHCSQA09)
      Correcting errors: Do not use correction tape/fluid, scribble over, etc. Instead, draw a
      single line through the error & initial, then enter correct material. (BHCSQA09)
          Only original authors may make alterations.
          Reviewers or supervisors may not edit original authors but may supply an addendum
          with dated signature.
      Acronyms & Abbreviations: Use only universal and County-designated acronyms and
      abbreviations. A list is available at www.acbhcs.org/providers under the QA tab.
       (BHCSQA09)



Record Storage:
Clinical records contain Protected Health Information (PHI) covered by both state and federal
confidentiality laws. Providers are required to safeguard the information in the record against
loss, defacement, tampering or use by unauthorized persons. (CFR1) (CFR2) (CC1)

Alameda County BHCS requires that clinical records be stored in a "double locked" manner
(e.g., in a locked filing cabinet located within a locked office). If records must be transported,
maintain the "double locked" and safeguarding requirement (e.g., transported in a locked box in
a locked vehicle trunk and not left in an unattended vehicle). Electronic Health Records (EHR)
must be stored in a password-protected computer located within a locked room. (BHCSQA09)




Section 8, page 5                           12-2010
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