Library: Policy

317:30-5-283. Documentation of records

Issued 7-1-10

All behavioral health services will be reflected by documentation in the patient records.

• (1) All assessment, testing, and treatment services/units billed must include the following:

  • (A) date;

  • (B) start and stop time for each session/unit billed;

  • (C) signature of the provider;

  • (D) credentials of provider;

  • (E) specific problem(s), goals, and/or objectives  addressed;

  • (F) methods used to address problem(s), goals and objectives;

  • (G) progress made toward goals and objectives;

  • (H) patient response to the session or intervention; and

  • (I) any new problem(s), goals and/or objectives identified during the session.

• (2) For each Group psychotherapy session, a separate list of participants must be maintained.

• (3) Testing will be documented for each date of service performed which should include at a minimum, the objectives for testing, the test administered, the results/conclusions and interpretation of the tests, and recommendations for treatment and/or care based on testing and analysis.