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

Jan 17, 2018 · reference in this Manual and adhere to the forms guidelines identified in MHSUS Policy 211-09. 4. Required documents include an accurate Assessment, Client Plan, and On-going Care Notes (Progress Notes). Remember that the medical records, both electronic and paper, are legal documents. 5.

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