Documentation

Documentation A. All services must be documented on a treatment plan and approved, signed and dated by a licensed practitioner operating within their scope of practice. B. The following must be documented in the beneficiary's case record for each service provided: 1. Type of service provided, 2. Date of service, 3. Length of time spent providing the service, 4. Start and end times of sessions, 5. Names of all individuals receiving or participating in the service, 6. Summary of session, 7. Explanation of how the service relates to the goals and objectives established in the treatment plan, 8. Name and title of servicing provider, and 9. Signature and credentials of servicing provider/practitioner. C. Community mental health services subject to certification by the Department of Mental Health (DMH) must be documented according to the DMH Record Guide and any supplemental instructions provided by DMH in effect at the time the service is provided.