CLINICAL DOCUMENTATION GUIDE - marinhhs.org

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 Manual v 1/17/2018 3 Objectives 23 Interventions 24 5 progress notes 26 progress Note Format (SIRP)

Jan 17, 2018 · progress notes. 8. Each progress note must show that the service was “medically necessary”. Progress notes should clearly indicate the type of service provided and how the service is medically necessary to address an identified area of impairment, and the progress (or lack of progress) in treatment.

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

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