Clinical Documentation - Crisis Response Network

Clinical Documentation
A New Employee Orientation (NEO) Required Training
June 2012
Module Overview
In this module, you will learn about clinical
documentation and how to enhance your clinical
documentation skills. More specifically, by the
time you are ready to take the post-test, you will:
• Understand the components of the clinical record
• Learn the keys to effective documentation
• Identify the key concepts of medical
necessity, person-centered care, and
concurrent documentation
• Recognize and comprehend the DAP and SOAP
formats for writing progress notes
• Understand the impact of Data Validation on
• Examine fraud and abuse related to documentation
Documentation Overview
Understanding the contents of the
clinical record will help you better assist
a member/family receiving services.
Documentation demonstrates a clear link between
the assessment, service plans and service delivery.
The documentation included in the member’s file
provides insight into their past experiences, current
situations and future goals - information that
serves as a solid foundation for a successful clinical
Complete, accurate and timely clinical documentation is vital
to the success of the member/family experience!
Standards for documentation are listed in detail in
Provider Manual Section 4.2 ‘Behavioral Health
Medical Records Standards’
Documentation Overview (continued…)
Documentation is not an optional activity!
• Documentation is a clinical process/responsibility that is a direct
reflection of the types and quality of care provided to a member.
• Documentation is the major source or avenue for communication
of information between the member, the family, the clinical team,
and any other individuals involved with the member or family –
documentation makes continuity and coordination of care possible.
• Documentation demonstrates a clear link between the
assessment, service planning and the service delivery processes.
• Documentation is person-centered, member-directed,
and a dynamic process.
• Documentation validates the procedures and
services that may be billed on your behalf.
• Documentation is not the same as a productivity report.
Documentation Overview (continued…)
A couple of key concepts that pertain to
Person-Centered Care: members/families are actively
involved in assessment, service planning and service delivery.
We strive for this throughout the course of services and it is
made apparent through all forms of documentation!
Medical Necessity: services provided to members must be in
accordance with, or meet the needs of their diagnosis.
Conversely, the diagnosis should justify and match with the
services a member is receiving.
Medically necessary covered services means those covered
services provided by qualified providers within the scope of their
practice to prevent disease, disability and other adverse
health/mental conditions, to their progression or to prolong life.
Documentation Overview:
The Clinical Record
As noted, accurate and complete clinical records are
vital. These clinical files/records are full of important
information - information that is specific to the
member/family. However, there are some similarities
for all clinical records, including what is contained
within them.
All clinical records must include, at minimum, the
• General member contact and
demographic information
• Financial information (i.e., AHCCCS
• Assessments, service plans and
progress notes
• Authorizations to release information
Documentation Overview:
The Clinical Record (continued…)
Depending on the specific needs of the member, the
clinical record may also contain the following:
• Communication with other agencies/entities
(i.e., the courts, Child Protective Services,
Vocational Rehabilitation)
• Lists of medications prescribed and notes
from the prescriber (i.e., psychiatrist,
specialist, primary care physician)
• Legal documents
• Lab reports
Continue on to learn more about required documents and
documentation information of the clinical record…
Required Documentation:
When an individual enters the public behavioral health
system in Arizona, a comprehensive clinical assessment is
completed. In order to engage the member/family in the
assessment, the assessment may take more than one
session to complete.
Why is this initial
clinical assessment
This assessment allows
the member/family to
provide necessary
information for a solid
clinical relationship to
begin to develop, and for
appropriate services to
What happens during
this assessment?
The member/family
shares strengths,
successes, hopes,
needs and reasons for
seeking services. A
diagnosis and
foundation for the
service plan results.
Required Documentation:
Assessments (continued…)
Assessments have important characteristics.
They are:
• Strength-based, family friendly, and culturally
• Clinically sound
• Complete
• Comprehensive
• An accurate reflection of the member’s condition
• Timely
We continually and informally ‘assess’ our members during
each contact we have with them. However, after the
initial/intake assessment, a formal assessment must be
completed, at minimum, every year.
Required Documentation:
Service Plan
A service plan is a living document that is regularly
updated to meet the changing needs and
service/treatment goals of the member/family.
The service plan is the member’s/family’s plan for services, not the
plan of the agency or clinician. It is developed, reviewed and
updated by the clinical team, which includes the member/family.
The plan must be written in such a way so the member/family can
easily understand the terminology, service objectives and
responsibilities. When possible, include the member’s own statements.
The member/family must agree with the service/treatment
objectives, listed services and outcome goals.
What’s included in a service plan?…
Required Documentation:
Service Plan (continued…)
Each service plan includes the following:
• Identified member/family vision, needs and goals
• Measurable objectives and timeframes to address those identified needs
and goals
• Distinct services, including frequency, of both covered and
informal/community services
• Current measures as well as desired and achieved outcome measures
• Member/family strengths (and their intended use)
• Review date of the plan (usually 30-90 days)
• Discharge Plan (if applicable)
For complete Assessment &
Service Plan requirements
see Provider Manual Section
3.9 - Assessment and
Service Planning
• Appropriate signatures and dates (including the member’s, showing
he/she accepts the plan)
Progress notes tie together all the items in
the client’s clinical file…
Required Documentation:
Progress Notes - General
Progress notes are a critical component of required
documentation. As services are delivered, the clinician
or caseworker must keep detailed and accurate records.
Information must be in the clinical file to document
phone calls, face to face sessions, other provided
services and activities, missed appointments, attempts
to contact the member/family, etc.
Why are progress notes so important?
• Encounters with members served yields information for agency
• The progress note provides an assessment of the member and
family’s status at that moment of contact; notes track progress.
• The notes provide a basis for upcoming service planning.
• Progress notes provide a record of up-to-the-minute communication
for all parties involved with the member/family.
Progress Notes - General
Progress notes reflect specifics, including:
• The member’s/family’s goals.
• The therapeutic intervention and specific services provided.
• The member’s or family’s response to the
intervention/services and progress toward the goals.
• The status of the service plan implementation.
• Day-to-day changes and progress - or lack of progress.
• Objective occurrences/changes in the member’s/family’s life
regarding relationships, heath, employment, etc.
Some general guidelines for completing all
progress notes…
Progress Notes - Requirements
There are many guidelines for accurate progress note
completion - here are some key points…
Refer to Provider Manual Section 4.2: Behavioral Health
Medical Records Standards.
• Include accurate start and stop times for each distinct service provided or
activity performed.
• Date and sign all entries with date, title and credentials (BHP, BHT, BHPP).
Add ‘late entry’ if note is entered after the date the service was provided.
• Be sure to document separately each service provided - billable or not and all activities you perform (phone calls, face-to-face encounters,
supervision for/staffing of case, etc.).
• Each note must reference the diagnosis, including an indicator that clearly
identifies whether the progress note is for a new diagnosis or the
continuation of a previous diagnosis.
If notes are recorded on paper: use blue or black ink; write legibly; never alter
written material - for errors put a single line through the incorrect information,
write ‘error’, date and initial - do not erase or cross out!!
Progress Notes - Guidelines
Be specific, factual and accurate…
• Don’t use jargon or highly technical terms.
• Spell out abbreviations/acronyms that are not widely known/utilized.
• Do integrate member’s words, thoughts or quotes where appropriate.
Use quotation marks when quoting member directly.
• Use specifics and qualifiers such as “as evidenced by” as appropriate.
• Include facts and direct observations. Minimize the use of your
impressions and opinions, and when you do utilize these, indicate that
they are your opinions and/or impressions.
• When referencing another professional, include their full name, title
and contact information when indicated.
• Use member’s first name in documentation, but do not use other
family member names (use father, stepbrother, etc.). Don’t use other
client/member names.
Progress Notes - Guidelines
Additional points to remember when writing
progress notes…
Be Objective & Factual
• Describe what is observed,
not what is assumed.
• Avoid interpreting or
expressing your opinions.
Document Thoroughly
• If it’s not documented, it didn’t happen!
• Include specific member responses to,
and outcomes of services and activities.
Remember: Encounters/Claims = Billing
• Justification for all billed encounters must be
documented in the progress note.
• See the ADHS/DBHS Covered Services Guide and your
agency policies for time documentation.
• Split out your non-billable services/activities from your
billable services/activities - but be sure to document all
services and activities you perform!
Progress Notes - Guidelines
The key concept of concurrent documentation is a
practice that can provide many benefits…
Concurrent Documentation is the practice of writing progress
notes with the member. The benefits of doing this include:
• Being person-centered, helping the member to feel more
involved and empowered
• Reduces member anxiety/concern about what is being
• Increases accuracy of documented information
• Ensures individualized documentation (not ‘canned’ notes)
• Reduces backlog of unwritten notes
Concurrent Documentation may not always be
possible or practical… use it when you can!
Electronic Documentation
Many agencies utilize computers to record information, write
progress notes, and maintain up-to-date and accurate clinical
files. There are some benefits and challenges to electronic
• Easy to maintain the clinical record and to keep the information
within neat, in order and accurate
• Allows you to easily correct progress notes
• Writing progress notes on a computer in front of the member
may alienate them, or seem to them disengaging or too clinical
• Having the member view the screen as you
compose the note, providing input/feedback
• Jotting notes on paper, then transferring the
complete progress note into the electronic
file after the member departs
Progress Notes Verbiage - Examples
Therapeutic intervention
Courtney participated in Art Therapy
for 1 hour this date. She spoke of
her drinking while drawing a selfportrait. We discussed strategies to
help reduce her drinking.
Objective observation
Stella arrived to session 22
minutes late. She was observed
to be malodorous and her
speech was slurred.
Progress toward goals
Mikhail provided copy of semester’s grades; received B’s and C’s. Also
brought copy of a scholarship of interest. Discussed his goal of utilizing
Voc Rehab services to attend New Hope Community College. He said he
sees this as a “positive possibility.”
Objective occurrence
John stated he has been hired
today at Walton’s Plumbing. He
begins work on 06/01/2011.
Services provided
Picked up and delivered a food box
to Sam; transported Sam to
appointment with PCP at 3:00pm.
Progress Notes Verbiage - Examples
It is important to be as specific as possible…
Poor Progress Notes
Carey seemed upset today.
(not clear or factual)
Moreno is drinking again.
(not clear or factual)
Better Progress Notes
Carey cried throughout the 30 minute
session. Stated she is “upset” and “unhappy.”
Moreno reported he has drunk to excess the
last 5 nights. He stated he has been hung
over each morning.
Porter was late for his
appointment, as usual.
He said he overslept.
(judgmental / not factual)
Porter arrived 15 minutes late for
appointment. Discussed with him that he has
been late for last 4 sessions. He reports he
has had “problems oversleeping.”
Lindy complained about
Paul and other male
staff; she dislikes men.
Lindy stated, “I feel uncomfortable with Paul
and Tim when they lead group.” She says she
is “unsure why she feels this way.”
(opinion / not factual)
Progress Notes - Formats
While using a specific progress note format is not mandated by
CPSA, we will review 2 common formats for writing progress
notes; see your supervisor to find out your agency’s method.
Using a format for your progress notes can help you organize
the content and increase the focus of the note, while helping to
avoid unnecessary information and writing.
Format of Progress Notes: SOAP
SOAP = Subjective, Objective, Assessment, Plan
Format of Progress Notes: DAP
DAP = Data, Assessment, Plan
Some agencies using the DAP note format combine Subjective
and Objective information together under the Data section of DAP
Progress Notes - DAP Notes
Format of Progress Notes: DAP
DAP = Data, Assessment, Plan
Data: any general
information on the
session, issues addressed,
member’s situation - that
relate to services
Assessment: objective
measures of the
member’s current
emotional, symptomatic
and/or functioning status
Plan: action to be
taken by member, staff
person, and others to
address member needs
and goals
Includes member self report
& your observations/actions;
a summary of the main
issues presented during the
session and the
Includes member
presentation, functional or
symptomatic improvement or
decline, progress toward
goals, responses to
interventions, effectiveness of
service plan.
Includes action steps,
next steps, referrals,
any refusal of services,
outreach & follow up
Progress Note Example: DAP Note
Service Plan Goal Addressed: Sala would like to make more friends but gets very anxious when
talking to people she doesn’t know. Over the next three months she will practice - at least four times
with her case manager - ways to talk with people she doesn’t know.
6/30/11 – (Start Time 1:00pm – Stop Time 2:30 pm) Sala McKeggan
DATA: Engaged Sala in relationship-building exercise at the office from the “How to
Make Friends” Program. Sala enthusiastically engaged this worker in role-playing,
showing how she would approach someone she’d like to make friends with. Worker
modeled for her some other skills/scripts she might want to try. Sala practiced these
skills with this worker for almost an hour.
ASSESSMENT: Sala appeared to enjoy the exercise/practice, looking much more
relaxed at the end of this discussion than when we began. This is the third session we
have worked on initiating relationships, and Sala is adding to her socialization skills, as
she remembers and utilizes techniques we worked on in previous sessions. Overall her
progress in this area is significant, as Sala reports now feeling much more confident in
initiating relationships, where three months previous she feels she would “never have
even thought about initiating a new relationship”.
PLAN: Sala will continue to work on solidifying and expanding her socialization skills,
eventually trying out these new skills with individuals with whom she works. Once
comfortable with using these skills, this worker will help Sala to generalize these skills to
other social situations. This goal will be addressed during our continuing weekly
Tamie Cochrane, BHT
This note supports encountering for the Covered Service ‘Living Skills Training’
Progress Notes - SOAP Notes
Format of Progress Notes: SOAP
SOAP = Subjective, Objective, Assessment, Plan
Subjective: the member’s/family’s goals or reasons for accessing
services; identifying service plan goal addressed during the
encounter; can be recorded in the member’s own words.
Objective: the intervention or service provided, the
clinician’s observations, including the range of emotions
that the member presents.
Assessment: the clinician’s opinion of the situation,
including progress toward goals and the identification of
strengths and improvements and member response to
Plan: the ‘next steps’ to be taken toward the service plan goals,
including interventions; include all parties involved and timeframes.
Progress Note Example: SOAP Note
Service Plan Goal Addressed: In order to remain drug free, Clark will spend at least six hours each
week doing positive activities that he enjoys and make him feel better about himself.
Clark West
Start: 1:30pm
End: 3:00pm
Subjective: Worker visited Clark at his home. He identified listening and playing music
as one activity that he does instead of doing drugs. He is setting aside an hour or two
each day to listen to music, and wants to start playing guitar again. He does not
currently have a guitar and wants to save up for one, but reports “it feels almost
impossible for me to set money aside for my guitar.”
Objective: This worker spent one hour showing Clark how to set up a simple household
budget and savings plan using the established agency curricula ‘Simple Budgeting’.
Assisted Clark with paperwork to request that $25 of each of his SSI checks be deposited
directly into his savings account.
Assessment: Clark appears to be committed to not using drugs as evidenced by his
willingness and enthusiasm to learn and undertake new behaviors. He appeared to grasp
the basics of budgeting as he explained back to this worker the steps he would be
required to take each month in order to stick to his budget.
Plan: Continue to monitor/support Clark’s budget plan, reinforcing budgeting skills with
him as needed. Continue weekly meetings with Clark at his home to ensure support of
his positive activities and monitor budget goals.
Carleena Middleton, MS, BHT
This note supports encountering for the Covered Service ‘Living Skills Training’
Progress Notes - Practice
On the next slides, three different sample
progress notes documenting member
contact/encounters are shown.
Review each of these notes, identifying what
you consider to be the positive/correct
components of each note, as well as any
shortcomings or missing components of each
For reference, compare these samples
to the DAP and SOAP progress note
examples from the previous slides.
Practice - Note 1
7/30/11 Tammy came to meeting today with case manager.
She was very angry. We discussed ways to approach her
roommate when she wears Tammy’s clothes.
• No start/stop times.
• With no times, how can billable units be
• No location of meeting.
• No signature, credentials, or date of note.
• What goal in the service plan was addressed?
• What was the outcome of the discussion w/
• How did author know Tammy was angry? Should
list observations to support this statement, or
use ‘as evidenced by…’.
• Is this a billable service? If so, what service was
• No diagnosis referenced.
• No DAP or SOAP format evident; no indication
of a ‘Plan’ (what happens next).
• Date of the meeting
• ????.... a very poor note
Practice - Note 2
4/1/12 1:00-2:30pm Mtg. w/ C.R. Mo. in wtg. rm. Not
DTS/DTO. Followed-up w/ Paul, he’ll sit in for next med.
appt. Called Mo. later and told her.
Too many abbreviations.
Followed up w/ Paul regarding what?
Who is the client?
Who is not DTS/DTO? C.R.? Mo.? And this is
as evidenced by what?
What goal in the service plan was addressed?
Is this a billable service? If so, what service
was provided?
The note does not at all describe how the
billed 90 min. was utilized.
‘Called Mo. later’ is Case Management - this
is a different service so it needs to be
documented in a separate note.
No signature, credentials, or date of note.
No diagnosis referenced.
No DAP or SOAP format evident.
• Date and start/stop times
• ????.... again, a very poor note.
Practice - Note 3
3/9/12 10:00-10:30 a.m. Member came to appointment
with case manager. He said that he will be hanging out
with his friends this weekend. Member stated he spoke
with his cousin on the phone this morning, they decided
the cousin will go out with client and his friends this
weekend. At first he could not think of anything he would
like to do but decided he would go to a car show at Reid
Park. Member talked about his favorite kind of car, stated
that he likes Toyotas, “They are reliable and have good
engines, but I don’t think there will be one at the car
show”. I listened and acknowledged that client was able to
connect with friends and his cousin. Member also
discussed feeling happy that he will meet with the
Vocational Specialist because he is ready to work. He was
giddy with excitement like a kid, and reported, “I can’t
wait to have a paycheck again!” Fred Jones, BHT 3/9/12
(See next slide for discussion)
Practice - Note 3 (Discussion)
3/9/12 10:00-10:30 a.m. Member came to appointment with case manager. He said that he will be hanging out with his friends this
weekend. Client stated he spoke with his cousin on the phone this morning, they decided the cousin will go out with client and his
friends this weekend. At first he could not think of anything he would like to do but decided he would go to a car show at Reid Park.
Client talked about his favorite kind of car, stated that he likes Toyotas, “They are reliable and have good engines, but I don’t think
there will be one at the car show”. I listened and acknowledged that client was able to connect with friends and his cousin. Client also
discussed feeling happy that he will meet with the Vocational Specialist because he is ready to work. He was giddy with excitement
like a kid, and reported, “I can’t wait to have a paycheck again!”
Fred Jones, BHT 3/9/12
No location of meeting.
Did not use member’s first name.
What goal in the service plan was addressed?
Difficult to determine which billable service (if
any) was provided.
Too much detail was included about things not
pertinent to treatment (social plans; favorite type
of car).
Little information documented regarding
employment (which probably is a service plan
Note did not list the name, agency or contact
information of the Voc. Spec. (collateral contact).
No diagnosis referenced.
No DAP or SOAP format evident; no indication of a
‘Plan’ (what happens next).
• Date and start/stop times
• Signature, credentials, date of
note present.
• Client quotes utilized - though
quotes do not seem to pertain
to treatment or service goals.
Progress Notes
Final Points to Remember
Include and support:
• what covered service was provided
• what skills the client demonstrated
• client responses to interventions/services
• your and other staff interactions and interventions
• what progress has been made re: goals/needs/objectives
on the service plan
Be objective and factual
Note should relate to the service plan and services provided
Collateral contacts - provide all information
Avoiding judgmental and flowery language
Remember… If it isn’t documented, then it didn’t happen!
There is a system in place that reviews member
records for proper clinical documentation…
Data Validation
Data Validation studies/audits are performed by
CPSA to identify problems and educate providers in
order to reduce visits by CPSA’s Compliance
Department and the ADHS/DBHS Office of Program
Integrity (OPI).
Data Validation studies are performed to determine
the quality of the corresponding documentation for
member encounters. (encounter = billable service)
Data Validation Studies are done quarterly for the
CSPs and semi-annually for Subcontractors.
What are the major items/specifics these Data
Validation studies focus on?…
Documentation: Data Validation
Data Validation Studies = Information in the
clinical record/progress notes is compared with
other submitted encounter data:
• The comparison should show that covered
services are documented/encountered:
• In a timely manner
• Completely (no omissions)
• Correctly
The progress note must contain a complete and accurate
description of covered services provided in the encounter,
supporting the definition of the service encountered for, per the
Covered Services Guide service definitions.
Documentation: Data Validation
Areas of Review:
Timeliness - claims must be submitted to CPSA within 45 days for CSPs
or Direct Contract Providers & 90 days for Subcontractors (See Provider
Manual Section 6.2 - Submitting Claims and Encounters to the RBHA for
specific guidelines). For Fee for Service - 180 days clean claim status
effective: 07/01/11.
Omissions - all documented services are billed/encountered and
documentation exists in the chart for an encounter sent to CPSA.
Correctness - information accurately represents the services provided:
date of service (inaccurate date of service can cause omissions)
service/billing code (HCPC or CPT)
place of service (11, 12, 99 other – must specify location where
service was
modifier (HN vs. HO) reimbursement is affected
member’s diagnosis code (taken from the applicable assessment if the note is
not written by someone qualified to diagnose)
number of billable units (determined from your service start and stop times)
There are some ‘risk areas’ where Data Validation errors commonly occur…
“Risk areas”
• Documentation is incomplete, insufficient and/or illegible.
• Progress note does not detail/support the services
provided/billed for. Hint: use Covered Services Guide service
code description verbiage (i.e. - taught, demonstrated,
assisted) to help support documentation and service billed.
• Failure to include in note reason for encounter, history,
findings, clinical impression, plan of care, date and identity of
• No rationale provided for ordering diagnostic or ancillary
services (labs, x-rays, etc…).
• CPT, HCPC and ICD-9 (billing) codes not supported by record
- service does not support diagnosis or service plan goals.
• Health risk factors not identified.
Our last module topic - fraud and abuse relating to documentation…
Fraud and Abuse
Fraud and abuse is an important issue in
all aspects of our daily work duties and
Fraud and abuse can occur around
documentation and other record-keeping
Documentation fraud is
serious, against the law, and
can result in fines, sanctions,
or criminal action against you
and/or your agency.
Fraud and Abuse: Defining Fraud
Fraud: An intentional deception or
misrepresentation made by a person
with the knowledge that the
deception could result in some
unauthorized benefit to himself or
some other person.
It includes any act that constitutes
Fraud under applicable Federal or State
Applicable Laws & Regulations
31 USC § 3729- 3733 False Claims
A.R.S. 13-2311 Fraudulent Schemes
and Practices
A.R.S. 36-2918 Medicaid False
A.R.S. 36-2918.01 Duty to Report
Fraud and Abuse
A.A.C. R9-22-101 Civil Monetary
Penalties & Assessments
Fraud and Abuse: Examples…
Examples of fraud and abuse…
• Falsification of clinical documentation (i.e., a licensed
therapist documented in the medical record that a member
had been seen multiple times for therapy. In fact, the
member was not seen).
• Intentionally using incorrect billing codes; Billing for noncovered services; Misrepresentation of services.
• Alteration of a claim or progress note; Double billing; False
data submitted.
• Inadequate or missing documentation resulting in denied
• Services provided by unqualified providers.
• Administrative/Financial Actions that include the following:
 Kickbacks
 Falsifying credentials
 Fraudulent enrollment practices
Fraud and Abuse: Defining Abuse
Abuse: Provider practices that
are inconsistent with sound
fiscal, business, or medical
practices, and result in
unnecessary cost to the Medicaid
program, or in reimbursement
for services that are not medical
Fraud and Abuse: Examples…
More examples of fraud and abuse…
• Unsigned documentation and assessments
• Personal purchases on the company credit card
• Theft of inventory items
• Theft of cash from deposits
• Falsifying time card with time not worked
• Using company vehicle for personal use
• Using company phone for personal calls
Waste and wasteful practices are now being
scrutinized. Waste: Spending that can be
eliminated, including over-utilization of services,
without reducing quality of care.
Fraud and Abuse: Taking Action
If you know or, or even suspect fraud and/or abuse are
being committed at your agency, you are required to
report this. First contact your supervisor OR your
supervisor’s supervisor. You may also talk with your
Human Resources Department or your Compliance
If these avenues are inappropriate for your situation,
you may also call:
CPSA Fraud & Abuse Hotline: 520-318-6964
ADHS/DBHS Fraud & Abuse Hotline: 866-569-4927
AHCCCS Office of Inspector General: 888-487-6686
All of these calls can be made anonymously.
Documentation… In Conclusion
• Remember, good clinical documentation is an
important part of successful treatment.
• Practice concurrent documentation when you can.
• Use a structured format as your guide in writing
progress notes.
• Ensure services provided are relevant for the
member’s diagnosis and needs.
• Make sure your progress note supports the services
provided and encountered for.
Still have questions? Please ask your clinical supervisor. They
can help you learn the protocols of your agency and provide you
guidance and feedback.
You can also find answers to your documentation questions in the
appropriate Provider Manual sections.…
Documentation: The Provider Manual
A great source for learning more about accurate
and proper documentation is the Provider Manual…
Standards for documentation are listed in detail in
Provider Manual Section 4.2 ‘Behavioral Health Medical
Records Standards’
For complete Assessment and Service Plan requirements see
Provider Manual Section 3.9 ‘Assessment and Service Planning’
For more information regarding Fraud & Abuse refer to
Provider Manual Section 7.1’Fraud & Program Abuse Reporting’
When documenting Covered Services in progress notes, and
for billing requirements, refer to the ADHS/DBHS Covered
Services Guide:
The ADHS/DBHS Covered Services Guide is online here:
Documentation…In Conclusion
Documentation is vitally
important - doing it correctly
is a critical part of your job.
Thank you for your time
and attention.
Please complete the
Post Test/Final Exam
at this time.

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