Chart Review Diane Davis LCSW Informed Consent Have

Chart Review Diane Davis, LCSW

Informed Consent Have “yes” response to the first 2 questions Client/Staff signatures (youth-parent/guardian signs) Advanced directive instructions offered to adults must…

HIPAA Privacy Practices one time only

Acknowledgement of Receipt of the Medi-Cal Guide one time only

Assessments Does the presenting problem / symptoms support the diagnosis?

Does medical necessity describe functional impairment? Goes into strangers homes Has no friends Evictions due to threatening phone call to neighbors Fights resulting in ER visits

Secondary AOD Diagnosis?

Client

functional impairment directly related to dx Arrests No friends Evictions Fights resulting in ER visits

Observable

Objectives must include all components Functional Impairment Observable/ Measureable Related to Diagnosis Baseline & Target

Frequency Duration

Signed by Clinician/LPHA If Integrated Plan-Psychiatrist must sign. No signature-No billing

Must be signed, on time by client

Timeline gaps = No billing

Progress Note Format

Describe Intervention Response Treatment

Billable or Info Note Can I bill travel time for a home visit if I client isn’t home? No What if I speak to a parent/other family member? Only if you are providing a mental health collateral service that is in the client plan.

Productions