Transcription of CLINICAL DOCUMENTATION MANUAL - Contra Costa County
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CLINICAL DOCUMENTATION MANUAL - 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 Revisions to the Plan 17 Components of the Partnership Plan 17 Partnership Plan Process Elements 17 Component Details and Examples 18 Partnership Plan Dates 18
BHSD Clinical Documentation Manual, Rev. June 2021 Page 7 of 121 2.1. GENERAL PRINCIPLES OF DOCUMENTATION 1. All Providers must refer and adhere to CCBHS-MHP Policy 709-MH, Quality Management/Utilization Review: Documentation Standards. 2. All CBOs who currently utilize an Electronic Health Record (EHR) must adhere to the UR Signature
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