Transcription of CLINICAL DOCUMENTATION GUIDE - Contra Costa County
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CLINICAL DOCUMENTATION GUIDE - Contra Costa County
CLINICAL DOCUMENTATION GUIDE 2017 Contra Costa County BEHAVIORAL HEALTH Contra Costa County DOCUMENTATION Manual v 2017 2 TABLE OF CONTENTS Chapter 1 Introduction/Compliance Why do we have this manual? 4 Compliance 5 Utilization Review 6 Chapter 2 General Principles of DOCUMENTATION General Principles of DOCUMENTATION 7 Signatures 9 Co-Signatures 9 Chapter 3 Establishment of Medical Necessity Flow of CLINICAL Information 10 Assessment 10 Medical Necessity 11 Components of Medical Necessity 13 Diagnostic Criteria 13 Impairment Criteria 13 Intervention Criteria 14 Chapter 4 Treatment Planning Partnership Plan for Wellness 15 Client Participation and Signatures 16 Timeliness of Partnership Plans 16
This Clinical Documentation Manual is to be used as a reference guide and is not a definitive single source of information regarding chart documentation requirements. This manual includes information based on the following sources: Code of Federal Regulations (CFR) 45 and 42, the California Code of
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