Chart Review

Charla Heibel Meier, MFT

Consents

Have “yes” response to the first 2 questions

Client/Staff signatures (youth-parent/guardian signs)

Advanced directive instructions offered to

adults

Informed Consent must…

one time only

HIPAA Privacy Practices

one time only

Acknowledgement of Receipt of the Medi-Cal Guide

Assessment

Assessments

Does the presenting problem / symptoms support the diagnosis?

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

Secondary AOD

Diagnosis?

Client

functional impairment directly

related to dx

Evictions No

friends

Arrests

Fights resulting in ER visits

Observable

Functional Impairment

Related to Diagnosis

Observable/ Measureable

Baseline &

Target

Objectives must include all components

Frequency

Duration

Signed by Clinician/LPHA

No signature-No billing

Must be signed, on time by client

Timeline gaps = No billing

Progress Note Format

Describe

Intervention

Response

Treatment

Can I bill travel time for a home visit if the 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

Productions