General Documentation Rules

Question 1

co-signature of a note means…

Answer 1

the co-signer has supervised the service delivery and assumes responsibility and liability for the service.

all staff without a bachelor’s degree in a mental health field or 2 years experience providing services must have all notes co-signed until education/experience requirement has been met and supervisor determines staff is competent

Question 2

Medical Necessity is substantiated by the following:

Answer 2

An included Dx.

functional Impairment

Intervention Criteria

Question 3

Impairment criteria for medical necessity

Answer 3

impairment in an important area of life functioning

probability of significant decompensation

probability that a person under 21 will not progress developmentally in a satisfactory manner

Question 4

Intervention criteria for medical necessity

Answer 4

the focus of the intervention is to address the impairment

it is expected that the intervention will reduce the impairment, prevent deterioration in an important area of life functioning or allow a child to progress developmentally

the condition wouldn’t be responsive to physical he alt care-based tx.

Question 5

clinical loop

Answer 5

Assessment with leading to included diagnosis,

Client Treatment Plan where dx. and impairments are used to establish tx. goals/objectives and the proposed interventions to effect the identified objectives;

Progress Note documenting services relaters back to an intervention identified on the treatment plan; progress notes should document progress the client is making towards the goal.

Question 6

timeframe for completing an assessment

Answer 6

within 60 days of the initiation of services related to assessment or treatment.

Question 7

Assessment for returning clients must be completed within…

Answer 7

60 days of initiation of services related to assessment or treatment;

Question 8

clients who’ve NOT had treatment terminated for 180 days of inactivity must have a … done at least every 3 years

Answer 8

Assessment Addendum or Adult Full Assessment

Question 9

assessment addendum must be completed…

Answer 9

when there is additional or changing information; prior to the provision of any services not justified by the existing assessment.