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Library: Policy

317:30-5-589. Documentation of records

Revised 7-1-07

     All behavioral health case management services rendered must be reflected by documentation in the records.  In addition to a complete behavioral health case management service plan documentation of each session must include, but is not limited to:

  • (1) date;

  • (2) person(s) to whom services are rendered;

  • (3) start and stop times for each service;

  • (4) original signature of the service provider (original signatures for faxed items must be added to the clinical file within 30 days);

  • (5) credentials of the service provider;

  • (6) specific service plan needs, goals and/or objectives addressed;

  • (7) specific activities performed by the behavioral health case manager on behalf of the child related to advocacy, linkage, referral, or monitoring used to address needs, goals and/or objectives;

  • (8) progress or barriers made towards goals and/or objectives;

  • (9) member (family when applicable) response to the service;

  • (10) any new service plan needs, goals, and/or objectives identified during the service; and

  • (11) member satisfaction with staff intervention.

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