Documenting Services. Each service listed below requires a progress note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. CONTRACTOR shall use the Placer County System of Care CARE Form 041 to ensure that Medi-Cal required elements are completed, regardless of whether the service is billable to Medi-Cal or a non-billable activity. Each note must include the Date of Service, Activity Code, Location of Service, and Duration (minutes) of Service. Progress notes should be computer generated. Documentation time shall be included as part of the service provided. Documentation must be completed at the time service is provided and should normally not exceed 10 minutes for every hour of service provided. Time used for Progress Note documentation shall be included in "duration of service" time recorded on Event Monitoring Slip, Progress Note and monthly invoice.
3.6.1. CONTRACTOR shall submit a copy of original documentation for each service provided with its monthly invoices. Documentation may include but not be limited to assessment, medical necessity form, client service plan, outpatient services treatment authorization request form, and progress notes.
Documenting Services. Each service listed below requires a progress note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. The Contractor shall use the Placer County System of Care CARE Form 041 to ensure that Medi-Cal required elements are completed. Each note must include the Date of Service, Activity Code, Location of Service, and Duration (minutes) of Service. Progress notes should be computer generated. Documentation time shall be included as part of the service provided. Documentation must be completed at the time service is provided and should normally not exceed 10 minutes for every hour of service provided. Time used for Progress Note documentation shall be included in “duration of service” time recorded on Event Monitoring Slip, Progress Note and monthly invoice. The Contractor shall submit a copy of original documentation for each service provided with its monthly invoices. Documentation may include but not be limited to assessment, medical necessity form, client service plan, and outpatient services treatment authorization request form. Assessment/Evaluation: The assessment is a clinical analysis of the history and current status of the client’s mental, emotional or behavioral functioning; appraisal of the client’s community functioning in several areas including living situation, daily activities, social support systems, health status and diagnosis. Included in the assessment shall be any relevant physical health condition, presenting problems, mental status exam, special risk factors, medication history, allergies and history of adverse reactions to medications, mental health treatment history, pre-natal and perinatal events, developmental history, a five axis diagnosis, client strengths. Plan Development: This activity would be utilized during the treatment planning that must occur after the assessment is completed and/or when completing an Outpatient Services Treatment Authorization Request form. When used to develop a client plan, documentation should include: Diagnosis, psychiatric symptoms present and in what context, observable and measurable treatment goals to be addressed in therapy and planned, clinically appropriate strategies for treatment. When used in preparation of the Outpatient Services Treatment Request Form, documentation should include presenting problems, strategies employed during treatment, current status of psychiatric symptoms or change in status that represents a critica...
