Common use of Documenting Services and Service Definitions Clause in Contracts

Documenting Services and Service Definitions. 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 COUNTY CARE Form 041 or equivalent to ensure that Medi-Cal required elements are completed. Each note must include all elements set forth by DHCS. . Progress notes shall be computer generated. Documentation time shall be included as part of the service provided. Documentation should be completed within 3 business days from the date the service was provided, with the exception of notes for crisis services which shall be completed within 24 hours. The length of documentation time should be commensurate with the duration of the service. Time used for Progress Note documentation shall be included in “duration of service” time recorded on CONTRACTOR’S Event Monitoring Slip, Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face to face service delivery time in any instance. Driving time between CONTRACTOR’s service locations is not billable time. 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, treatment 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 multiple domains including trauma, social and life circumstances, health status and diagnosis. The assessment shall follow standardized criteria as outlined by DHCS and the COUNTY.

Documenting Services and Service Definitions. 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 COUNTY CARE Form 041 or equivalent to ensure that Medi-Cal required elements are completed. Each note must include all elements set forth by DHCS. the Date of Service, Activity Code, Location of Service, and Duration (minutes) of Service. Progress notes shall be computer generated. Documentation time shall be included as part of the service provided. Documentation should must be completed within 3 business days from at the date the time service was is provided and should normally not exceed 10 minutes for every hour of service provided, with the exception of notes for crisis services which shall be completed within 24 hours. The length of documentation time should be commensurate with the duration of the service. Time used for Progress Note documentation shall be included in “duration of service” time recorded on CONTRACTOR’S Event Monitoring Slip, Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face to face service delivery time in any instance. Driving time between CONTRACTOR’s service locations is not billable time. 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, treatment planClient Services 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 multiple domains several areas including traumaliving situation, daily activities, social and life circumstancessupport systems, health status and diagnosis. The Included in the assessment shall follow standardized criteria as outlined by DHCS be any relevant physical health condition, presenting problems, mental status exam, special risk factors, medication history, allergies and the COUNTYhistory of adverse reactions to medications, mental health treatment history, pre-natal and perinatal events, developmental history, a five-axis diagnosis, and client strengths.

Documenting Services and Service Definitions. Each service listed below requires a progress noteProgress Note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. CONTRACTOR shall may use the COUNTY CARE Form 041 Form041 or equivalent its own progress note form, if it has all the Medi-Cal required elements, to ensure that Medi-Cal required elements are completed. Each note must include all elements set forth by DHCS. the date of service, activity code, location of service, and duration (minutes) of service. Progress notes Notes shall be computer computer-generated. Documentation time shall be included as part of the service provided. Documentation should must be completed within 3 business days from at the date the time service was provided, with the exception of notes for crisis services which shall is provided and should not be completed within 24 hours. The length of documentation time should be commensurate with the duration of the serviceexcessive. Time used for Progress Note documentation shall be included in “duration of service” time recorded on CONTRACTOR’S Event Monitoring Slip, the Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face to face-to-face service delivery time time, except in any instancerare instances. Driving time between CONTRACTOR’s service certified locations is not billable time. CONTRACTOR shall submit a copy of original documentation for each , however, it is allowable between service provided with its monthly invoices. Documentation may include but not be limited to assessment, medical necessity form, treatment plan, and outpatient services treatment authorization request formlocations in the community. Assessment/Evaluation: The assessment is CONTRACTOR shall provide a clinical analysis of the history and current status of the clientchild or youth’s mental, emotional or behavioral functioning; , appraisal of the clientchild or youth’s community functioning in multiple domains several areas including traumaliving situation, daily activities, social and life circumstancessupport 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, and child or youth strengths. CONTRACTOR may use its’ own assessment form or COUNTY’S Biopsychosocial Assessment form, CARE015. The assessment must be updated at least every year, or every three months for youth meeting the Xxxxx X. lawsuit subclass. Plan Development: This activity is included as part of the CONTRACTOR’S 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 service plan, CONTRACTOR’S documentation shall follow standardized criteria 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 Authorization Request Form, CONTRACTOR’S documentation shall include presenting problems, strategies employed during treatment, current status of psychiatric symptoms or change in status that represents a critical need for this service and meets medical necessity guidelines, and what additional treatment is necessary. Therapy – Individual/Group: A service activity that is a therapeutic intervention which focuses primarily on symptom reduction as a means to improve functional impairments. CONTRACTOR’S Progress Notes shall include a description of attempted intervention and/or what was accomplished by the client, family (when applicable) and the CONTRACTOR toward treatment goals or necessary interventions at the time service was delivered and a description of any changes in the child or youth’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. This section also applies to Intensive Home Based Services (IHBS). CONTRACTOR must write a group Progress Note for each child or youth attending a group session, with the goal for each group clearly articulated, and each child or youth’s individualized response to the group interventions documented. The group Progress Note formula must be clearly indicated on every group note, with the correct calculations conducted. Rehabilitation, Case Management/Brokerage, and Intensive Care Coordination: CONTRACTOR must write a Progress Note for each Rehabilitation or Case Management/Brokerage contact, which shall contain date of service, activity code, location of service, duration (minutes) of service and a description of what was accomplished by the client and/or CONTRACTOR staff. The note must reflect any new significant information or changes as they may occur. An ICC note shall also document why this intensive service was needed vs. using a case management service. Psychiatry/Medication Monitoring: CONTRACTOR is required to provide psychiatric services including consultation with primary care physicians, psychiatric screening and evaluation, medication prescribing, monitoring and support, and inpatient follow-up. CONTRACTOR must write a Progress Note for each psychiatric service provided. CONTRACTOR shall permit any member of the direct service program to document the date and time when a beneficiary has ingested any prescribed or nonprescription medication, denote any side effects the beneficiary has experienced as reported by the beneficiary and/or as observed by direct program staff as consistent with DHCS STRTP Mental Health Regulations, unless amended by DHCS. Documentation shall be in a Medication Administration Record (MAR) by direct program staff, or equivalent. Documentation in the form of a specialty mental health service claim is not considered an equivalent or permissible form of documentation. Crisis Intervention: A service, lasting less than 24 hours, to or on behalf of a child or youth for a condition that requires more timely response than a regularly scheduled visit. Service activities include but are not limited to one or more of the following: assessment, collateral and therapy. Crisis intervention is distinguished from crisis stabilization because it is delivered by providers who do not meet the crisis stabilization contact, site, and staffing requirements described in Title 9, Sections 1840.338 and 1840.348. Crisis intervention services must be documented as outlined by DHCS and the COUNTYherein.

Documenting Services and Service Definitions. Each service listed below requires a progress noteProgress Note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. CONTRACTOR shall may use the COUNTY CARE Form 041 Form041 or equivalent its own progress note form, if it has all the Medi-Cal required elements, to ensure that Medi-Cal required elements are completed. Each note must include all elements set forth by DHCS. the date of service, activity code, location of service, and duration (minutes) of service. Progress notes Notes shall be computer computer-generated. Documentation time shall be included as part of the service provided. Documentation should must be completed within 3 business days from at the date the time service was provided, with the exception of notes for crisis services which shall is provided and should not be completed within 24 hours. The length of documentation time should be commensurate with the duration of the serviceexcessive. Time used for Progress Note documentation shall be included in “duration of service” time recorded on CONTRACTOR’S Event Monitoring Slip, the Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face to face-to-face service delivery time time, except in any instancerare instances. Driving time between CONTRACTOR’s service certified locations is not billable time. CONTRACTOR shall submit a copy of original documentation for each , however, it is allowable between service provided with its monthly invoices. Documentation may include but not be limited to assessment, medical necessity form, treatment plan, and outpatient services treatment authorization request formlocations in the community. Assessment/Evaluation: The assessment is CONTRACTOR shall provide a clinical analysis of the history and current status of the clientchild or youth’s mental, emotional or behavioral functioning; , appraisal of the clientchild or youth’s community functioning in multiple domains several areas including traumaliving situation, daily activities, social and life circumstancessupport 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, and child or youth strengths. CONTRACTOR may use its’ own assessment form or COUNTY’S Biopsychosocial Assessment form, CARE015. The assessment must be updated at least every year, or every three months for youth meeting the Xxxxx X. lawsuit subclass. Plan Development: This activity is included as part of the CONTRACTOR’S 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 service plan, CONTRACTOR’S documentation shall follow standardized criteria 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 Authorization Request Form, CONTRACTOR’S documentation shall include presenting problems, strategies employed during treatment, current status of psychiatric symptoms or change in status that represents a critical need for this service and meets medical necessity guidelines, and what additional treatment is necessary. Therapy – Individual/Group: A service activity that is a therapeutic intervention which focuses primarily on symptom reduction as a means to improve functional impairments. CONTRACTOR’S Progress Notes shall include a description of attempted intervention and/or what was accomplished by the client, family (when applicable) and the CONTRACTOR toward treatment goals or necessary interventions at the time service was delivered and a description of any changes in the child or youth’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. This section also applies to Intensive Home Based Services (IHBS). CONTRACTOR must write a group Progress Note for each child or youth attending a group session, with the goal for each group clearly articulated, and each child or youth’s individualized response to the group interventions documented. The group Progress Note formula must be clearly indicated on every group note, with the correct calculations conducted. Rehabilitation, Case Management/Brokerage, and Intensive Care Coordination: CONTRACTOR must write a Progress Note for each Rehabilitation or Case Management/Brokerage contact, which shall contain date of service, activity code, location of service, duration (minutes) of service and a description of what was accomplished by the client and/or CONTRACTOR staff. The note must reflect any new significant information or changes as they may occur. An ICC note shall also document why this intensive service was needed vs. using a case management service. Psychiatry/Medication Monitoring: CONTRACTOR is required to provide psychiatric services including consultation with primary care physicians, psychiatric screening and evaluation, medication prescribing, monitoring and support, and inpatient follow-up. CONTRACTOR must write a Progress Note for each psychiatric service provided. CONTRACTOR shall permit any member of the direct service program to document the date and time when a beneficiary has ingested any prescribed or nonprescription medication, denote any side effects the beneficiary has experienced as reported by the beneficiary and/or as observed by direct program staff as consistent with DHCS STRTP Mental Health Regulations, unless amended by DHCS. Documentation shall be in a Medication Administration Record (MAR) by direct program staff, or equivalent. Documentation in the form of a specialty mental health service claim is not considered an equivalent or permissible form of documentation. Crisis Intervention: A service, lasting less than 24 hours, to or on behalf of a child or youth for a condition that requires more timely response than a regularly scheduled visit. Service activities include but are not limited to one or more of the following: assessment, collateral and therapy. Crisis intervention is distinguished from crisis stabilization because it is delivered by providers who do not meet the crisis stabilization contact, site, and staffing requirements described in Title 9, Sections 1840.338 and 1840.348. Crisis intervention services must be documented as outlined by DHCS and the COUNTYherein.

Documenting Services and Service Definitions. 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 may use the COUNTY CARE Form 041 or equivalent its own progress note form, if it has all the Medi-Cal required elements, to ensure that Medi-Cal required elements are completed. Each note must include all elements set forth by DHCS. the Date of Service, Activity Code, Location of Service, and Duration (minutes) of Service. Progress notes shall be computer generated. Documentation time shall be included as part of the service provided. Documentation should must be completed within 3 business days from at the date the time service was provided, with the exception of notes for crisis services which shall is provided and should not be completed within 24 hours. The length of documentation time should be commensurate with the duration of the serviceexcessive. Time used for Progress Note documentation shall be included in “duration of service” time recorded on the CONTRACTOR’S Event Monitoring Slip, Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face to face-to-face service delivery time except in any instancerare instances. Driving time between CONTRACTOR’s service certified locations is not billable time. CONTRACTOR shall submit a copy of original documentation for each , however, it is allowable between service provided with its monthly invoices. Documentation may include but not be limited to assessment, medical necessity form, treatment plan, and outpatient services treatment authorization request formlocations in the community. 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 multiple domains several areas including traumaliving situation, daily activities, social and life circumstancessupport systems, health status and diagnosis. The Included in the assessment shall follow standardized criteria 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, ICD10 diagnosis, and client strengths. The CONTRACTOR may use its own assessment form or the COUNTY Biopsychosocial Assessment form, CARE 015. Plan Development: This activity is included as part of 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 shall 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 Authorization Request Form, documentation shall include presenting problems, strategies employed during treatment, current status of psychiatric symptoms or change in status that represents a critical need for this service and meets medical necessity guidelines, and what additional treatment is necessary. Therapy – Individual/Group: A service activity that is a therapeutic intervention which focuses primarily on symptom reduction as a means to improve functional impairments. All progress notes shall contain a description of attempted intervention and/or what was accomplished by the client, family (when applicable) and the CONTRACTOR toward treatment goals or necessary interventions at the time service was delivered and a description of any changes in client’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. A group progress note must be written for each client attending the group session, with the goal for each group clearly articulated, and the client’s individualized response to the group interventions documented. The group progress note formula must be clearly indicated on every group note, with the correct calculations conducted. Additionally, the CONTRACTOR shall list all clients attending the group session on the Event Monitoring Form each time a group session is held, identifying the clients, the group service by activity code, date of service and length of group in minute increments, including documentation time. Rehabilitation, IHBS, ICC, and Case Management/Brokerage: A progress note must be written for each Rehabilitation or Case Management/Brokerage contact and shall contain date of service, activity code, location of service, duration (minutes) of service and a description of what was accomplished by the client and/or staff. The note must reflect any new significant information or changes as they may occur. Psychiatry/Medication Monitoring: Psychiatric services including consultation with primary care physicians, psychiatric screening and evaluation, medication prescribing, monitoring and support, and inpatient follow-up is required. A progress note must be written for each psychiatric service provided. Crisis Intervention: A service, lasting less than 24 hours, to or on behalf of a beneficiary for a condition that requires more timely response than a regularly scheduled visit. Service activities include but are not limited to one or more of the following: assessment, collateral and therapy. Crisis intervention is distinguished from crisis stabilization by being delivered by providers who do not meet the crisis stabilization contact, site, and staffing requirements described in Title 9, Sections 1840.338 and 1840.348. Crisis intervention services must be documented as outlined by DHCS and the COUNTYherein.

Documenting Services and Service Definitions. Each service listed below requires a progress noteProgress Note, which must meet medical necessity guidelines and meet Medi-Cal requirements as described by service and activity code. CONTRACTOR shall may use the COUNTY CARE Form 041 Form041 or equivalent its own progress note form, if it has all the Medi-Cal required elements, to ensure that Medi-Cal required elements are completed. Each note must include all elements set forth by DHCS. the date of service, activity code, location of service, and duration (minutes) of service. Progress notes Notes shall be computer computer-generated. Documentation time shall be included as part of the service provided. Documentation should must be completed within 3 business days from at the date the time service was provided, with the exception of notes for crisis services which shall is provided and should not be completed within 24 hours. The length of documentation time should be commensurate with the duration of the serviceexcessive. Time used for Progress Note documentation shall be included in “duration of service” time recorded on CONTRACTOR’S Event Monitoring Slip, the Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face to face-to-face service delivery time time, except in any instancerare instances. Driving time between CONTRACTOR’s service certified locations is not billable time. CONTRACTOR shall submit a copy of original documentation for each , however, it is allowable between service provided with its monthly invoices. Documentation may include but not be limited to assessment, medical necessity form, treatment plan, and outpatient services treatment authorization request formlocations in the community. Assessment/Evaluation: The assessment is CONTRACTOR shall provide a clinical analysis of the history and current status of the clientchild or youth’s mental, emotional or behavioral functioning; , appraisal of the clientchild or youth’s community functioning in multiple domains several areas including traumaliving situation, daily activities, social and life circumstancessupport 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, and child or youth strengths. CONTRACTOR may use its’ own assessment form or COUNTY’S Biopsychosocial Assessment form, CARE015. The assessment must be updated at least every year, or every three months for youth meeting the Xxxxx X. lawsuit subclass. Plan Development: This activity is included as part of the CONTRACTOR’S 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 service plan, CONTRACTOR’S documentation shall follow standardized criteria 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 Authorization Request Form, CONTRACTOR’S documentation shall include presenting problems, strategies employed during treatment, current status of psychiatric symptoms or change in status that represents a critical need for this service and meets medical necessity guidelines, and what additional treatment is necessary. Therapy – Individual/Group: A service activity that is a therapeutic intervention which focuses primarily on symptom reduction as a means to improve functional impairments. CONTRACTOR’S Progress Notes shall include a description of attempted intervention and/or what was accomplished by the client, family (when applicable) and the CONTRACTOR toward treatment goals or necessary interventions at the time service was delivered and a description of any changes in the child or youth’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. This section also applies to Intensive Home Based Services (IHBS). CONTRACTOR must write a group Progress Note for each child or youth attending a group session, with the goal for each group clearly articulated, and each child or youth’s individualized response to the group interventions documented. The group Progress Note formula must be clearly indicated on every group note, with the correct calculations conducted. Rehabilitation, Case Management/Brokerage, and Intensive Care Coordination: CONTRACTOR must write a Progress Note for each Rehabilitation or Case Management/Brokerage contact, which shall contain date of service, activity code, location of service, duration (minutes) of service and a description of what was accomplished by the client and/or CONTRACTOR staff. The note must reflect any new significant information or changes as they may occur. An ICC note shall also document why this intensive service was needed vs. using a case management service. Psychiatry/Medication Monitoring: CONTRACTOR is required to provide psychiatric services including consultation with primary care physicians, psychiatric screening and evaluation, medication prescribing, monitoring and support, and inpatient follow-up. CONTRACTOR must write a Progress Note for each psychiatric service provided. CONTRACTOR shall permit any member of the direct service program to document the date and time when a beneficiary has ingested any prescribed or nonprescription medication, denote any side effects the beneficiary has experienced as reported by the beneficiary and/or as observed by direct program staff as consistent with DHCS STRTP Mental Health Regulations, unless amended by DHCS. Documentation shall be in a Medication Administration Record (MAR) by direct program staff, or equivalent. Documentation in the form of a specialty mental health service claim is not considered an equivalent or permissible form of documentation. CONTRACTOR shall permit COUNTY nurse direct access to prescribing physicians, including psychiatrists, for communication relating to prescribing, medication monitoring support, refills, and court orders. Crisis Intervention: A service, lasting less than 24 hours, to or on behalf of a child or youth for a condition that requires more timely response than a regularly scheduled visit. Service activities include but are not limited to one or more of the following: assessment, collateral and therapy. Crisis intervention is distinguished from crisis stabilization because it is delivered by providers who do not meet the crisis stabilization contact, site, and staffing requirements described in Title 9, Sections 1840.338 and 1840.348. Crisis intervention services must be documented as outlined by DHCS and the COUNTYherein.

Documenting Services and Service Definitions. 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 COUNTY CARE Form 041 or equivalent to ensure that Medi-Cal required elements are completed. Each note must include all elements set forth by DHCS. the Date of Service, Activity Code, Location of Service, and Duration (minutes) of Service. Progress notes shall be computer generated. Documentation time shall be included as part of the service provided. Documentation should must be completed within 3 business days from at the date the time service was is provided and should normally not exceed 10 minutes for every hour of service provided, with the exception of notes for crisis services which shall be completed within 24 hours. The length of documentation time should be commensurate with the duration of the service. Time used for Progress Note documentation shall be included in “duration of service” time recorded on CONTRACTOR’S Event Monitoring Slip, Progress Note and monthly invoice. It is recognized that some services will be held in community settings and some billing for travel time is necessary as part of documentation. Travel time shall not exceed face to face service delivery time in any instance. Driving time between CONTRACTOR’s service locations is not billable time. 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, treatment planClient Services 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 multiple domains several areas including traumaliving situation, daily activities, social and life circumstancessupport systems, health status and diagnosis. The Included in the assessment shall follow standardized criteria 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, and client strengths. Plan Development: This activity is included as outlined part of 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 shall 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 Authorization Request Form, documentation shall include presenting problems, strategies employed during treatment, current status of psychiatric symptoms or change in status that represents a critical need for this service and meets medical necessity guidelines, and what additional treatment is necessary. Therapy – Individual/Group: A service activity that is a therapeutic intervention which focuses primarily on symptom reduction as a means to improve functional impairments. All progress notes shall contain a description of attempted intervention and/or what was accomplished by DHCS the client, family (when applicable) and CONTRACTOR toward treatment goals or necessary interventions at the time service was delivered and a description of any changes in client’s level of functioning. The notes must reflect any significant new information or changes as they may occur and a follow-up plan. A group progress note must be written for each client attending the group session, with the goal for each group clearly articulated, and the COUNTYclient’s individualized response to the group interventions documented. The group progress note formula must be clearly indicated on every group note, with the correct calculations conducted. Additionally, CONTRACTOR shall list all clients attending the group session on the Event Monitoring Form each time a group session is held, identifying the clients, the group service by activity code, date of service and length of group in minute increments, including documentation time. Rehabilitation and Case Management/Brokerage: A progress note must be written for each Rehabilitation or Case Management/Brokerage contact and shall contain date of service, activity code, location of service, duration (minutes) of service and a description of what was accomplished by the client and/or staff. The note must reflect any new significant information or changes as they may occur.