CLINICAL DOCUMENTATION GUIDE

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BHRS DOCUMENTATION Manual v 1/17/2018 CLINICAL DOCUMENTATION GUIDE 2018 BEHAVIORAL HEALTH AND RECOVERY SERVICES BHRS DOCUMENTATION Manual v 1/17/2018 2 CONTENTS 1 INTRODUCTION/COMPLIANCE Why Do We Have This Manual? 5 Compliance 6 2 GENERAL PRINCIPLES OF DOCUMENTATION AND AUTHORIZATION TIMEFRAMES 7 General Principles Of DOCUMENTATION 7 Signatures 9 Establishment Of Service Authorization Period 9 Timeframes For Submission Of DOCUMENTATION For Service Authorization Admission 10 3 ESTABLISHMENT OF MEDICAL NECESSITY 13 Assessment 13 Medical Necessity 15 Components Of Medical Necessity 16 Diagnostic Criteria 16 Impairment Criteria 17 Intervention Related Criteria 17 4 TREATMENT PLANNING 18 Client Plan 18 Client Participation and Signatures 19 Timeliness of Client Plans 19 Revisions To The Plan 20 Components Of The Client Plan 20 Client Plan Dates 21 Client s Goals 21 Client Strengths 22 Obstacles to Goals 23 BHRS DOCUMENTATION

Jan 17, 2018 · correct Program Facility/Program and for the correct client. 10. Primary Total Time should be noted on each progress note. Primary total time is the time spent face-to-face with client plus any administrative time (e.g., documentation time …

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