Library: Policy

317:30-5-248. Documentation of records

Revised 9-12-14

     All outpatient behavioral health services must be reflected

by documentation in the member's records.

• (1) For Behavioral Health Assessments (see OAC 317:30-5-241), no progress notes are required.

• (2) For Behavioral Health Services Plan (see OOAC 317:30-5-241), no progress notes are required.

• (3) Treatment Services must be documented by progress notes.

  • (A) Progress notes shall chronologically describe the services provided, the member's response to the services provided and the member's progress, or lack of, in treatment and must include the following:

    • (i) Date;

    • (ii) Person(s) to whom services were rendered;

    • (iii) Start and stop time for each timed treatment session or service;

    • (iv) Original signature of the therapist/service provider; in circumstances where it is necessary to fax a service plan to someone for review and then have them fax back their signature, this is acceptable; however, the provider must obtain the original signature for the clinical file within 30 days and no stamped or photocopied signatures are allowed. Electronic signatures are acceptable following OAC 317:30-3-4.1 and 317:30-3-15;

    • (v) Credentials of therapist/service provider;

    • (vi)Specific service plan need(s), goals and/or objectives addressed;

    • (vii) Services provided to address need(s), goals and/or objectives;

    • (viii) Progress or barriers to progress made in treatment as it relates to the goals and/or objectives;

    • (ix) Member (and family, when applicable) response to the session or intervention;

    • (x) Any new need(s), goals and/or objectives identified during the session or service.

• (4) In addition to the items listed above in this subsection:

  • (A) Crisis Intervention Service notes must also include a detailed description of the crisis and level of functioning assessment;

  • (B) a list/log/sign in sheet of participants for each Group rehabilitative or psychotherapy session and facilitating qualified provider must be maintained; and

  • (C) for medication training and support, vital signs must be recorded in the medical record, but are not required on the behavioral health services plan;

• (5) Progress notes for PSR day programs may be in the form of daily or weekly summary notes and must include the following:

  • (A) Curriculum sessions attended each day and/or dates attended during the week;

  • (B) Start and stop times for each day attended;

  • (C) Specific goal(s) and/or objectives addressed during the week;

  • (D) Type of Skills Training provided each day and/or during the week including the specific curriculum used with the member;

  • (E) Member satisfaction with staff intervention(s);

  • (F) Progress or barriers made toward goals, objectives;

  • (G) New goal(s) or objective(s) identified;

  • (H) Signature of the lead qualified provider; and

  • (I) Credentials of the lead qualified provider.

• (6) Concurrent documentation between the clinician and member can be billed as part of the treatment session time, but must be documented clearly in the progress notes.