Library: Policy

317:30-5-599. Documentation of records

Revised 7-01-07

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

(1) date;
(2) person(s) to whom services were rendered;
(3) start and stop time for each service;
(4) original signature of the 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 needs to obtain the original signature for the clinical file within 30 days. No stamped or Xeroxed signatures are allowed);
(5) credentials of service provider;
(6) specific service plan need(s), 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 problem(s), goals and/or objectives;
(8) progress or barriers made towards goals and/or objectives;
(9) client (and family, when applicable) response to the services;
(10) any new individual plan of service need(s), goals and/or objectives identified during the service; and
(11) member satisfaction with staff intervention(s).