RECORDS MANAGEMENT AND - NC

1 RECORDS MANAGEMENT . AND. DOCUMENTATION MANUAL. For Providers of Publicly-Funded Mental Health, Intellectual or Developmental Disabilities, and Substance Use Services and Local MANAGEMENT Entities-Managed Care Organizations North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services APSM 45-2. Effective December 1, 2016. i Revisions to the RECORDS MANAGEMENT and Documentation Manual [RM&DM] .. i Scope .. ii How to Use This Manual .. iii Chapter 1: General RECORDS Administration and Reporting Requirements .. 1-1. THE VALUE OF RECORDKEEPING .. 1-1. ADMINISTRATIVE REQUIREMENTS .. 1-1. Personnel RECORDS .. 1-2. Indices and Registers .. 1-2. Record Retention and Disposition .. 1-2. LME-MCO 1-2. Provider Responsibility .. 1-3. RECORDS MANAGEMENT Requirements .. 1-5. RECORDS Retention and Disposition Schedules for LME-MCOs and Provider Agencies .. 1-5. DHHS RECORDS Retention and Disposition Schedule for Grants.

2 1-6. Destruction of RECORDS Not Listed in a Schedule .. 1-6. THE LME-MCO ADMINISTRATIVE RECORD FOR INDIVIDUALS SEEKING OR RECEIVING 1-6. TRANSFER OF RECORDS WHEN AN LME-MCO DISSOLVES OR MERGES .. 1-7. ADMINISTRATIVE STAFF SIGNATURE FILE .. 1-7. DATA REPORTING REQUIREMENTS .. 1-7. Documentation and Coordination of Standardized Processes for Screening, Triage, and Referral, Registration, Admission, and Discharge .. 1-8. Consumer Data Warehouse Reporting by LME-MCOs .. 1-8. When CDW Enrollment is Required .. 1-8. When CDW Enrollment is not Required .. 1-9. North Carolina Treatment Outcomes and Program Performance System [NC-TOPPS] .. 1-10. Incident and Death Reporting Documentation .. 1-11. Service End-Date Reporting to LME-MCOs .. 1-11. Chapter 2: The Clinical Service Record .. 2-1. PURPOSE OF A SERVICE 2-1. THE IMPORTANCE OF CLINICAL 2-1. TYPES OF CLINICAL SERVICE RECORDS .. 2-2. Pending RECORDS .. 2-2. Modified 2-2. Full Clinical Service 2-3.

3 Contents of a Full Clinical Service Record .. 2-3. ELECTRONIC MEDICAL RECORDS .. 2-5. ELECTRONIC HEALTH 2-5. MH/IDD/SU SERVICE ARRAY AND DOCUMENTATION REQUIREMENTS .. 2-5. Forms and Formats .. 2-6. CLOSURE OF CLINICAL RECORDS .. 2-6. Administrative Closure of Clinical Service RECORDS .. 2-7. PRIVACY AND SECURITY OF SERVICE RECORDS .. 2-7. Safeguards .. 2-8. Confidentiality .. 2-8. Transporting RECORDS .. 2-9. Storage and Maintenance of Service RECORDS .. 2-9. Chapter 3: Clinical Assessments and Evaluations .. 3-1. DOCUMENTING CLINICAL EVALUATIONS AND ASSESSMENTS .. 3-1. SERVICE ACCESS FOR INDIVIDUALS ENTERING THE SERVICE SYSTEM .. 3-1. THE COMPREHENSIVE CLINICAL ASSESSMENT .. 3-1. Basic Required Elements of a Comprehensive Clinical Assessment .. 3-2. Age- and Disability-Specific Guidelines for the Comprehensive Clinical Assessment .. 3-3. Services for Children and Youth .. 3-3. Adult Mental Health 3-3. Intellectual or Developmental Disability Services.

4 3-3. Substance Use Services .. 3-3. Other Instruments Used to Complete the Comprehensive Clinical Assessment for Specific Services .. 3-4. Detoxification Services .. 3-4. Driving While Impaired [DWI] Services .. 3-4. Juvenile Justice Substance Abuse Mental Health Partnerships [JJSAMHP] .. 3-4. NC-SNAP for Individuals with Intellectual or Developmental Disabilities .. 3-4. North Carolina Treatment Outcomes and Program Performance System [NC-TOPPS] .. 3-4. Supports Intensity Scale [SIS] for Individuals with Intellectual or Developmental Disabilities .. 3-5. Treatment Accountability for Safer Communities [TASC] .. 3-5. Work First / Substance Use Initiative .. 3-5. Medical Review of the Comprehensive Clinical Assessment .. 3-5. PSYCHOLOGICAL 3-6. RE-ASSESSMENTS .. 3-6. Chapter 4: Individualized Service Planning .. 4-1. PERSON-CENTERED THINKING AND INDIVIDUALIZED SERVICE PLANNING .. 4-1. THE PERSON-CENTERED PLAN .. 4-2. The Person-Centered Plan Format.

5 4-2. Required Components of the Person-Centered 4-2. The One-Page Profile .. 4-2. The Action 4-3. The Comprehensive Crisis Prevention and Intervention Plan [CPIP] .. 4-3. The Signature Page .. 4-4. Dating the Person-Centered Plan .. 4-4. The Completion Date of the Person-Centered Plan .. 4-4. Person-Centered Plan Completion Dates and Timelines .. 4-4. Signing the Person-Centered Plan .. 4-5. Signatures of Minors .. 4-6. REVIEW, REVISION, AND ANNUAL REWRITE OF THE PERSON-CENTERED PLAN .. 4-6. Reviews and Revisions .. 4-6. Documenting the Review .. 4-7. Signatures .. 4-7. Annual Rewrite .. 4-7. INDIVIDUAL SUPPORT PLAN .. 4-7. SERVICE PLAN REQUIREMENTS WHEN A PERSON-CENTERED PLAN FORMAT IS NOT REQUIRED .. 4-8. Chapter 5: Medical Necessity, Service Orders, and Service 5-1. MEDICAL NECESSITY .. 5-1. SERVICE ORDERS .. 5-1. Verbal Service Orders .. 5-2. SERVICE AUTHORIZATION .. 5-2. Service Authorization and Early and Periodic Screening, Diagnostic and Treatment [EPSDT].

6 5-2. Service Authorization for MH/IDD/SU Services .. 5-3. Reauthorization of Services .. 5-3. Appeals .. 5-3. SERVICE END-DATE REPORTING TO LME-MCOs .. 5-3. Chapter 6: Special Admission and Discharge Planning 6-1. MEDICAL EXAMINATIONS AS A SPECIAL ADMISSION REQUIREMENT .. 6-1. DISCHARGE PLANNING .. 6-1. DISCHARGE SUMMARY .. 6-1. SERVICE-SPECIFIC ADMISSION, DISCHARGE, OR TRANSITION PLANNING 6-2. Assertive Community Treatment [ACT] Team 6-2. Child and Adolescent Day Treatment .. 6-2. Child and Adolescent Residential Treatment Level III & Level IV .. 6-2. Medically Supervised or ADATC Detoxification/Crisis Stabilization .. 6-2. Psychiatric Residential Treatment Facilities [PRTF] .. 6-3. Admission .. 6-3. Discharge .. 6-3. Chapter 7: Service Notes and Service Grids .. 7-1. DOCUMENTING SERVICE PROVISION .. 7-1. Service Periods and General Time Frames for Entering Notes .. 7-1. CONTENTS OF A SERVICE NOTE .. 7-2. Shift Notes .. 7-2.

7 Service Notes When Providing Group Therapy .. 7-3. Service Notes When Provided by a Team .. 7-3. Service Note Requirements for Case MANAGEMENT Activities .. 7-4. PERIODIC 7-4. DAY/NIGHT SERVICES .. 7-4. TWENTY-FOUR HOUR 7-5. TIMELY DOCUMENTATION AND LATE ENTRIES .. 7-6. Late Entries .. 7-6. Late Entries Billable .. 7-6. Late Entries Not Billable .. 7-6. Dictation .. 7-7. Late Entry Procedures for Periodic Services .. 7-7. Late Entry Procedures for Day/Night Services .. 7-7. Day/Night Services Requiring Service Notes per Date of Service .. 7-7. Day/Night Services Requiring Weekly or Quarterly Service Notes .. 7-8. Late Entry Procedures for Twenty-Four Hour Services .. 7-8. Twenty-Four Hour Services Requiring a Service Note per Shift or per Date of Service .. 7-8. Twenty-Four Hour Services Requiring Monthly Service Notes .. 7-8. SERVICES FOR WHICH A MODIFIED SERVICE NOTE MAY BE USED .. 7-9. SERVICE GRID DOCUMENTATION .. 7-9. Required Elements of a Service Grid.

8 7-10. FAXED SERVICE NOTES .. 7-10. Chapter 8: General Documentation Procedures .. 8-1. DOCUMENTING IN SERVICE RECORDS .. 8-1. GENERAL DOCUMENTATION DOs AND DON'Ts .. 8-1. ABBREVIATIONS .. 8-2. CONSENT .. 8-2. Consent for Treatment .. 8-2. Consent for Research .. 8-3. SPECIAL PRECAUTIONS .. 8-3. TIMELY DOCUMENTATION AND LATE ENTRIES .. 8-3. CORRECTIONS IN THE SERVICE RECORD .. 8-3. Electronic RECORDS .. 8-3. Paper 8-4. SIGNATURES .. 8-4. Authenticated/Dated 8-5. Use of Rubber Stamps .. 8-5. Electronic Signatures .. 8-6. Countersignatures .. 8-7. SIGNATURES OF STAFF .. 8-7. Staff Signature File .. 8-7. Electronic Signatures of Staff .. 8-7. SIGNATURES OF INDIVIDUALS, PARENTS AND LEGALLY RESPONSIBLE PERSONS .. 8-8. In Loco Parentis and Consent for Minors .. 8-8. SIGNATURES OF INDIVIDUALS FROM OTHER AGENCIES .. 8-8. ELECTRONIC 8-9. SPECIAL SITUATIONS .. 8-9. Documentation of Suspected/Observed Abuse/Neglect/Exploitation .. 8-9.

9 Incident Reports .. 8-9. Chapter 9: Special Service-Specific Documentation Requirements & Provisions .. 9-1. AMBULATORY DETOXIFICATION SERVICES .. 9-1. ASSERTIVE COMMUNITY TREATMENT [ACT] TEAM SERVICES .. 9-1. BASIC BENEFIT SERVICES .. 9-1. BEHAVIORAL HEALTH PREVENTION EDUCATION SERVICES FOR CHILDREN AND ADOLESCENTS IN. SELECTIVE AND INDICATED POPULATIONS .. 9-2. CHILD AND ADOLESCENT DAY TREATMENT .. 9-2. CHILD AND ADOLESCENT RESIDENTIAL TREATMENT LEVEL I & II, FAMILY TYPE .. 9-3. CHILD AND ADOLESCENT RESIDENTIAL TREATMENT LEVEL II, PROGRAM TYPE .. 9-3. CHILD AND ADOLESCENT RESIDENTIAL TREATMENT LEVEL III & LEVEL IV .. 9-4. Initial Authorization 9-4. Consecutive Authorization Requirements .. 9-4. Other Requirements .. 9-5. COMMUNITY REHABILITATION PROGRAMS .. 9-5. COMMUNITY SUPPORT TEAM SERVICES .. 9-5. COURT-ORDERED CONSULTATION OR ASSESSMENT-ONLY DOCUMENTATION REQUIREMENTS .. 9-5. Alcohol and Drug Education Traffic School [ADETS].

10 9-5. Drug Education School [DES] .. 9-6. Assessment-Only Driving While Impaired [DWI] Services .. 9-6. DAY SUPPORTS (STATE-FUNDED).. 9-6. DEVELOPMENTAL DAY SERVICES BEFORE/AFTER SCHOOL AND SUMMER .. 9-6. DIAGNOSTIC ASSESSMENT .. 9-7. DRIVING WHILE IMPAIRED [DWI] SERVICES .. 9-7. DROP-IN CENTER SERVICES .. 9-8. INDEPENDENT LIVING .. 9-8. LONG-TERM VOCATIONAL SUPPORT SERVICES .. 9-9. MEDICALLY SUPERVISED OR ADATC DETOXIFICATION/CRISIS STABILIZATION .. 9-9. MEDICATION 9-9. NON-HOSPITAL MEDICAL DETOXIFICATION SERVICES .. 9-10. OPIOID 9-10. OUTPATIENT TREATMENT AND MEDICATION MANAGEMENT 9-10. PROFESSIONAL TREATMENT SERVICES IN FACILITY-BASED CRISIS PROGRAM .. 9-11. PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES [PRTF] .. 9-11. PSYCHOSOCIAL REHABILITATION [PSR] .. 9-11. Guidance for Documenting PSR Service Provision .. 9-11. RESIDENTIAL RECOVERY PROGRAMS FOR INDIVIDUALS WITH SUBSTANCE ABUSE DISORDERS AND. THEIR CHILDREN .. 9-12. Substance Abuse Non-medical Community Residential Treatment.