LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 401.02 Clinical Records Contents and Documentation Entry
 
  PROCEDURES
  1. The clinical record shall be complete, accurate, current, and legible.
  2. All clinical correspondence and correspondence received from outside sources related to a client shall be:
    1. Scanned into the Electronic Health Record (EHR) within three (3) working days of receipt, then destroyed in accordance with DMH Policy 401.01. 
    2. Scanned documents shall at a minimum contain the client's full name.
  3. All administrative correspondence not used for the purpose of treatment, (e.g., DCFS Detention Reports, Criminal History Information) received from outside sources, related to a client shall be:
    1. Scanned into the Non Disclosure Admin folder within the EHR within three (3) working days of receipt, then destroyed in accordance with DMH Policy 401.01.
    2. Scanned documents shall at a minimum contain the client’s full name.
    3. Information reviewed and used for the purpose of treatment and providing services to a client from any sources other than IBHIS (e.g., other EHR systems, Health Information Exchanges, emails, etc.), shall be referenced in the progress note.
    4. It shall not be copied and pasted into a client’s clinical record in IBHIS.
    5. It may be downloaded or printed from the outside system then uploaded or scanned into IBHIS in the Other Mental Health folder. 
  4. Clinical documentation shall be saved in draft within the EHR while in the process of being completed.
    1. For an assessment that takes multiple service contacts, the partially completed assessment form shall be saved in draft in the EHR, along with a final progress note documenting the assessment-related service provided that day within the timeframes identified in Policy Section III.
    2. When information is to be added to a saved draft assessment form prior to completion, the form shall be edited in the EHR and a progress note referencing the added sections shall be filed in the clinical record in accordance with Section E.
  5. Once a completed document is filed in the clinical record, it shall only be altered through the approved methods identified in the IBHIS Error Prevention and Correction Manual or with the approval of DMH Quality Assurance (QA) based on DMH Policy 501.06.
  6. Clinical records shall only contain information directly relevant to the treatment of the client. Examples of information that shall not be included in the clinical record include:
    • Administrative documents for the internal use of the program
 
  2. Critical incident reports/investigations and suspected abuse reports or consultations shall be documented in the Abuse Consult or Report/Critical Incident Report Log form in IBHIS and shall not be documented within a client’s progress note in order to prevent inadvertent disclosure of the name of reporting parties to clients and/or third parties.
    1. Critical incident reports/investigations include Safety Intelligence Reports and consultation about critical incidents with the appropriate governing body.
    2. Suspected abuse and Tarasoff (Duty to Protect) reports include reference to having made the report or consultation about potential abuse with the appropriate governing agency (e.g., Child Protective Services, Adult Protective Services).
  3. A signature, title and/or discipline, and license/registration/certification number (if applicable) shall be present on clinical documentation in accord with the Organizational Provider's Manual.
  4. Any document printed out (including electronic format) from the EHR shall:
    1. Be in accordance with approved disclosure practices from Health Information Management and DMH Policy
      1. Contracted providers must adhere to their agency’s disclosure practices.
    2. Contain the client's name and applicable identification number
    3. Include the date and time the document was printed
  5. If abbreviations are used, they shall be standard, industry-accepted abbreviations.
  6. All documentation in the clinical record shall be in English.
    • Note: Whenever non-English paper forms are used or non-English documentation is completed, an English version shall be attached to the non-English version.