CLINICAL DOCUMENTATION OVERVIEW
To begin treatment in therapy, you begin by conducting this
What is a Mental Health Assessment?
DBH is moving away from the Medical Model to this
What is a Person-Centered treatment Model?
This manual is used to help formulate a diagnosis
What is the DSM 5?
The Treatment Plan is developed and linked to areas identified in the person's ______________
What is the Mental Health Assessment?
If medical necessity criteria for SMHS is not met, you need to give the client one of these, keep a copy in their chart, and send a copy to Managed Care
What is a Notice of Adverse Benefit Determination (NOABD) form?
The assessment data provide the basis for determining whether medical criteria are met and for developing this
What is the Treatment Plan?
Since 2016, Fresno County DBH has adopted the use of these tools developed by the Mental Health Center of Denver
What is Reaching Recovery?
The DSM 5 is used for diagnostic purposes, and the ICD-10 code sets are used for
What is billing/claiming purposes?
All ________________ services, with the exception of the Assessment, must be included on the Treatment Plan
What is "planned services?"
The Fresno County Mental Health Plan treats people with ____________ to ___________ impairment
What is moderate to severe impairment?
All mental health services should be directed towards these
What are the Treatment Plan goals & objectives?
Instead of saying "he/she is mentally ill," or defining the person by their diagnosis/struggles/distress, use this language
What is "person is living with..." or "person is experiencing...?"
In order to establish medical necessity for SMHS, you must have a primary diagnosis that is
What is an Included mental health diagnosis
A _________ ___________ approach to identifying treatment goals includes obtaining what wellness looks like for the person served
What is person-centered?
All Mental Health Divisions of Fresno County DBH shall adhere to ________ ___________ and documentation standards set forth by DHCS and the FCMHP
What is medical necessity?
Progress Notes needs to support that services are this
What is medically necessary?
Instead of using the terms "clients" use these terms
What is "persons served?"
If an ICD-10 or DSM 5 diagnosis is not on the Included Diagnosis list, it is considered this
What is an Excluded Diagnosis?
The Treatment Plan must be developed with _______ days of the Assessment
What is 60 days?
If documentation standards are not in compliance, the FCMHP may ______________ the service(s)
What is disallow or recoup the service fees paid?
We don't bill for services when a person is in this type of setting
What is a "lockout" setting? (jail, juvenile hall, in an IMD or acute inpatient setting)
This rule understands and accommodates for the fact that not everyone wants to be treated the same way
What is the Platinum Rule?
Per Fresno County DBH policy, a Mental Health Assessment must be conducted at least every ______ years or when there is a significant change in the person's presentation
What is every two years?
The Treatment Plan is not valid without the _____________ signature
What is the Provider's signature?
If the provider is found to be out of compliance, a ______ of _________ will need to be completed and submitted to Managed Care
What is a Plan of Correction?