| (a) Mental health targeted case management documentation.
Mental health targeted case management services must be documented
in the individual's medical record. Case managers are required to
maintain a record of every individual receiving mental health targeted
case management, including:
(1) the name of the individual;
(2) the name of the comprehensive provider agency and
the name of the assigned case manager;
(3) the date, nature, content, and units of each service
received and whether goals specified in the recovery/treatment plan
have been achieved;
(4) whether the individual has declined services in
the recovery/treatment plan;
(5) the need for, and occurrences of, coordination
with other staff members;
(6) a timeline for obtaining needed services; and
(7) a timeline for reevaluation of the recovery/treatment
plan.
(b) Service documentation. The case manager must document
the following for each service provided:
(1) the event or behavior that occurs while providing
the service or the reason for the specific encounter;
(2) the person, persons, or entity, including other
staff members, with whom the encounter or contact occurred;
(3) a collateral contact that is directly related to
identifying the needs and supports for helping the individual access
services and managing the individual's care, including coordination
with other staff members;
(4) the recovery/treatment plan goal(s) that was the
focus of the service, including the progress or lack of progress in
achieving recovery plan goal(s);
(5) the specific intervention provided;
(6) the date the service was provided;
(7) the start and end time of the service;
(8) the mode of delivery used to provide the service
and if provided in person, the location where the service was provided;
and
(9) the signature of the case manager providing the
service, including credentials.
(c) Crisis service documentation. In addition to the
general documentation requirements described in subsection (b) of
this section, a staff member must document the following for crisis
intervention services:
(1) behavioral description of the presenting problem;
(2) lethality (e.g., suicide, violence);
(3) the individual's relevant substance use;
(4) the individual's relevant trauma, abuse, or neglect;
(5) all actions, including rehabilitative interventions
and referrals to other agencies, used by the provider of crisis intervention
services to address the problems presented;
(6) the response of the individual, and if appropriate,
the response of the LAR or primary caregiver and family members;
(7) the signature of the staff member providing the
service and a notation as to whether the staff member is an LPHA or
a QMHP-CS;
(8) any pertinent event or behavior relating to the
individual's treatment which occurs during the provision of the service;
(9) follow up activities, which may include referral
to another provider; and
(10) the outcome of the individual's crisis.
(d) Refusing mental health targeted case management
services. If the individual refuses mental health targeted case management
services, the assigned case manager must:
(1) document the individual's stated reason for the
refusal in the individual's medical record; and
(2) request that the individual sign a waiver of case
management services that is filed in the individual's medical record.
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