CLINICAL DOCUMENTATION GUIDE

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

Jan 17, 2018 · 7. Progress notes should provide enough detail so that auditors and other service providers can easily ascertain the client’s status and needs and understand why the service was provided without having to refer to previous progress notes. 8. Each progress note must show that the service was “medically necessary”.

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  Notes, Guide, Clinical, Clients, Documentation, Progress, Progress notes, Clinical documentation guide

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