I.  PURPOSE
 

To provide Los Angeles County Department of Mental Health (DMH) directly operated (DO) programs with policy and procedures related to the contents of the clinical record as well as the entry of documentation into the clinical record.

Contracted agencies shall develop an internal policy and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy. 
 

II.  DEFINITIONS
 

Clinical Documentation: Documentation of direct services, and activities supporting direct services, including progress notes and any other supporting documentation (e.g., assessment), and documentation of indirect services (e.g., Community Outreach Services).

Clinical Record: An official record containing all clinical information and services related to a client.
 

III.  POLICY

Practitioners shall complete all clinical documentation within three (3) business days of providing a service.

• Exception - clinical documentation for crisis services shall be completed within one calendar day.

For all clinical documentation requiring supervisor approval, the supervisor shall:

1. Review documentation by the end of the next scheduled work day (following the date the practitioner finalizes); and
2. Co-sign within three (3) business days.

• Exception - clinical documentation for crisis services shall be completed within one calendar day of finalization by the practitioner.

For DO practitioners, all clinical documentation shall be directly documented within the Electronic Health Record (EHR).

• Exceptions - Standardized screening/measurement tools and Evidence Based Practice worksheets may be completed outside the EHR and scanned.

The Quality Assurance (QA) Unit shall be responsible for developing paper versions of all forms to utilize during periods in which the EHR is unavailable.

DO providers shall follow the IBHIS Error Prevention and Correction Manual developed by QA for handling incomplete and/or untimely clinical documentation due to unforeseen circumstances. Contracted agencies shall have their own written procedures.

Contracted agencies shall have an EHR for all clinical documentation.  

• The manner and form in which contracted providers document within the system is at the discretion of the contractor, as long as it complies with Federal and State law and regulation, clinical/licensing standards, and the terms of the provider’s contract with the Department of Mental Health.
• All clinical documentation shall be stored within the EHR.  

Clinical records shall contain all information related to the client services provided in accordance with DMH Policies 401.03 and 401.04.
 

IV.  PROCEDURES
 

V.  AUTHORITIES