Chart Review
description
Transcript of Chart Review
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Chart Review
Diane Davis, LCSW
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Consents
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Have “yes” response to the first 2 questions
Client/Staff signatures (youth-parent/guardian signs)
Advanced directive instructions offered to
adults
Informed Consent must…
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one time only
HIPAA Privacy Practices
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one time only
Acknowledgement of Receipt of the Medi-Cal Guide
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Assessment
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Assessments Does the
presenting problem / symptoms support the diagnosis?
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Does medical necessity describe
functional impairment?
Evictions due to threatening phone call to neighbors
Has no friends
Goes into strangers homes
Fights resulting in ER visits
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Secondary AOD
Diagnosis?
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Client
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functional impairment directly
related to dx
Evictions No
friends
Arrests
Fights resulting in ER visits
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Observable
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Functional Impairment
Related to Diagnosis
Observable/ Measureable
Baseline &Target
Objectives must include all components
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Frequency
Duration
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Signed by Clinician/LPHAIf Integrated Plan-Psychiatrist
must sign.No signature-No billing
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Must be signed, on time by client
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Timeline gaps = No billing
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Progress Note Format
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Describe
Intervention
Response
Treatment
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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.
Billable or Info Note
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Productions