Provider Handbook

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All inpatient (including RTC and PHP) behavioral health records must contain the following:
 

• Psychiatric admission evaluation report within 24 hours of admission
• History and physical exam within 24 hours of admission (Note: The complete report must be documented within 72 hours of acute and RTC programs and within three working days for PHPs.)
• Individual and family therapy notes within 24 hours of procedure for acute care, detoxification, and RTC programs, and within 48 hours for PHPs
• Preliminary treatment plan within 24 hours of admission
• Master treatment plan within five calendar days of admission for acute care, 10 days for RTC care, five days for full-day PHPs, and seven days for half-day PHPs
• Family assessment report within 72 hours of admission for acute care and within seven days for RTCs and PHPs
• Nursing assessment report within 24 hours of admission
• Nursing notes at the end of each shift for acute and detoxification programs, after every 10 visits for PHPs, and at least once a week for RTCs
• Physician notes daily for intensive treatment, detoxification and rapid stabilization programs, twice per week for acute programs, and once per week for RTCs and PHPs
• Group therapy notes once per week
• Ancillary service notes once per week

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• Patient identification
• Informed consent for evaluation, treatment, and communications signed by the beneficiary or legal guardian
• Documentation showing communication with the beneficiary’s primary care physician

• Identified problems as determined by the beneficiary and/or family and the therapist
• Specific treatment interventions and goals
• Discharge plans

• Date, time, and length of therapy session
• Patient’s current clinical status evidenced by the presenting signs and symptoms
• Content of therapy session
• Therapeutic intervention(s) used and a description of the beneficiary’s response
• Summary of the beneficiary’s progress toward the treatment goals and discharge

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• A completed medication flow sheet or progress notes documenting current psychotropic medication(s), dosage(s), and date(s) of dosage changes
• Documentation of beneficiary education regarding possible medication side effects
• Documentation that the reason for medication was explained to the beneficiary
• Documentation of education for women of child-bearing age to avoid becoming pregnant while taking psychotropic medication and to notify psychiatrist immediately upon becoming pregnant
• Documentation of beneficiary understanding of medication education
• Record reflecting that Drug Enforcement Agency-scheduled drugs are avoided in the treatment of beneficiaries with a history of substance use disorder/dependency.

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If outside resources are utilized for care, the following documentation must be included:
 

• Documentation of the utilization of resources outside therapeutic encounters, including appropriate preventive services such as relapse prevention strategies, lifestyle changes, stress management, wellness programs, and referrals to community resources
• Prompt referral of beneficiaries who become homicidal, suicidal, or unable to conduct activities of daily living to the appropriate level of care

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