Behavioral Health Medical Record Documentation Requirements:

• Meet the State’s Medicaid program rules

• Reflect medical necessity and justify the treatment and clinical rationale

• Reflect active treatment

• Be complete, concise, and accurate, including the face-to-face time spent with the patient (for example, the time spent to complete a psychosocial assessment, a treatment plan, or a discharge plan)

• Be legible, signed, and dated

• Be maintained and available for review

• Be coded correctly for billing purposes