Documentation Standards


​​​​​​​​​Mental Health service providers (county-operated and contracted) are required to meet client chart documentation standards as established by Medi-Cal and the Division of Behavioral Health Services.  Providers are responsible for ensuring that clients meet medical necessity and target population guidelines, understand and apply both billable and non-billable service codes, and how to submit Medi-Cal claims that comply with State and Federal statutory and regulatory requirements.  The Division of Behavioral Health Services offers documentation trainings throughout the year. 

Below are brief descriptions of the trainings provided as well as a reference list of materials referred to during training.

Documentation Training is offered to provider staff throughout the year (see Training Calendar​​​).

Adult/Child Documentation Day 1:
Target Audience: Direct service staff and clinical supervisors

  • Introduction to the Mental Health Plan
  • Medical Necessity to the Mental Health Plan
  • Cultural Competence
  • Review of SUPT services available
  • Review Clinical Documentation Requirements/Standards
  • SmartCare requirements
  • CalAIM Assessment
  • Review of CANS, PSC-35, and ANSA
  • Care Plan Within Service Notes
  • Appropriate for SmartCare users and Providers with their own EHR

Adult/Child Documentation Day 2:
Target Audience: Direct service staff and clinical supervisors

  • Review Service Notes and Procedure Codes
  • Billable and Non-Billable Procedure Codes
  • Procedure Code Break Out Room Group Activity
  • Connects Clinical Practice and Documentation
  • MHSA/Support Services Procedure Codes (included for applicable programs)
  • Programs and Housing Plan
  • Appropriate for SmartCare users and Providers with their own EHR

Crisis Programs Documentation:
Target Audience: Direct service staff and clinical supervisors at crisis services programs 

  • Introduction to the Mental Health Plan
  • Medical Necessity
  • Cultural Competence
  • Diagnosis and Problem List
  • Documentation Requirements/Standards
  • Care Planning
  • Linkage for MH/SUPT Services
  • Service Notes
  • Classifications and Procedure Codes
  • Discharge/Transition Planning

See resource materials below related to documentation:

Claiming for Case Consultation

Members' Handbook

Sacramento County Approved Acronyms & Abbreviations ​

Care Plan-Treatment Plan Checklist

​​​​Best Practices Assessment Checklist

Group Attendance Sheet Template

Sacramento County Scanned Document Naming Convention Form​​

Discharge Options

QM FAQ​​​​​

For Policies & Procedures (P & P) related to documentation requirements, see our P & P webpage or send an email to QMInformation@saccounty.gov




 
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