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.

2 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 .. 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.

3 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. 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.

4 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.

5 3-3. Services for Children and Youth .. 3-3. Adult Mental health 3-3. Intellectual or Developmental Disability Services .. 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.

6 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 .. 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.

7 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].

8 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].

9 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. 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.

10 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 .. 7-10. FAXED SERVICE NOTES .. 7-10. Chapter 8: General documentation Procedures .. 8-1. DOCUMENTING IN SERVICE RECORDS .