Clinical Documentation A New Employee Orientation (NEO) Required Training

1. Clinical DocumentationA New Employee Orientation (NEO) Required Training June 2012

2. Module Overview In this module, you will learn about clinical documentation and how to enhance your clinical documentation skills. More specifically, by the time you are ready to take the post-test, you will: • Understand the components of the clinical record • Learn the keys to effective documentation • Identify the key concepts of medical necessity, person-centered care, and concurrent documentation • Recognize and comprehend the DAP and SOAP formats for writing progress notes • Understand the impact of Data Validation on documentation • Examine fraud and abuse related to documentation

3. Documentation Overview Understanding the contents of the clinical record will help you better assist a member/family receiving services. Documentation demonstrates a clear link between the assessment, service plans and service delivery. The documentation included in the member’s file provides insight into their past experiences, current situations and future goals - information that serves as a solid foundation for a successful clinical relationship. Complete, accurate and timely clinical documentation is vital to the success of the member/family experience! Standards for documentation are listed in detail in Provider Manual Section 4.2 ‘Behavioral Health Medical Records Standards’

4. Documentation Overview (continued…) Documentation is not an optional activity! • Documentation is a clinical process/responsibility that is a direct reflection of the types and quality of care provided to a member. • Documentation is the major source or avenue for communication of information between the member, the family, the clinical team, and any other individuals involved with the member or family – documentation makes continuity and coordination of care possible. • Documentation demonstrates a clear link between the assessment, service planning and the service delivery processes. • Documentation is person-centered, member-directed, and a dynamic process. • Documentation validates the procedures and services that may be billed on your behalf. • Documentation is not the same as a productivity report.

5. Documentation Overview (continued…) A couple of keyconcepts that pertain to documentation… Person-Centered Care: members/families are actively involved in assessment, service planning and service delivery. We strive for this throughout the course of services and it is made apparent through all forms of documentation! Medical Necessity: services provided to members must be in accordance with, or meet the needs of their diagnosis. Conversely, the diagnosis should justify and match with the services a member is receiving. Medically necessary covered services means those covered services provided by qualified providers within the scope of their practice to prevent disease, disability and other adverse health/mental conditions, to their progression or to prolong life.

6. Documentation Overview: The Clinical Record As noted, accurate and complete clinical records are vital. These clinical files/records are full of important information - information that is specific to the member/family. However, there are some similarities for all clinical records, including what is contained within them. All clinical records must include, at minimum, the following: • General member contact and demographic information • Financial information (i.e., AHCCCS eligibility) • Assessments, service plans and progress notes • Authorizations to release information

7. Documentation Overview: The Clinical Record (continued…) Depending on the specific needs of the member, the clinical record may also contain the following: • Communication with other agencies/entities (i.e., the courts, Child Protective Services, Vocational Rehabilitation) • Lists of medications prescribed and notes from the prescriber (i.e., psychiatrist, specialist, primary care physician) • Legal documents • Lab reports Continue on to learn more about required documents and documentation information of the clinical record…

8. Required Documentation: Assessments When an individual enters the public behavioral health system in Arizona, a comprehensive clinical assessment is completed. In order to engage the member/family in the assessment, the assessment may take more than one session to complete. Why is this initial clinical assessment completed? This assessment allows the member/family to provide necessary information for a solid clinical relationship to begin to develop, and for appropriate services to begin. What happens during this assessment? The member/family shares strengths, successes, hopes, needs and reasons for seeking services. A diagnosis and foundation for the service plan results.

9. Required Documentation: Assessments (continued…) Assessments have important characteristics. They are: • Strength-based, family friendly, and culturally responsive • Clinically sound • Complete • Comprehensive • An accurate reflection of the member’s condition • Timely We continually and informally ‘assess’ our members during each contact we have with them. However, after the initial/intake assessment, a formal assessment must be completed, at minimum, every year.

10. Required Documentation: Service Plan A service plan is a living document that is regularly updated to meet the changing needs and service/treatment goals of the member/family. The service plan is the member’s/family’s plan for services, not the plan of the agency or clinician. It is developed, reviewed and updated by the clinical team, which includes the member/family. The plan must be written in such a way so the member/family can easily understand the terminology, service objectives and responsibilities. When possible, include the member’s own statements. The member/family must agree with the service/treatment objectives, listed services and outcome goals. What’s included in a service plan?…

11. Required Documentation: Service Plan (continued…) Each service plan includes the following: • Identified member/family vision, needs and goals • Measurable objectives and timeframes to address those identified needs and goals • Distinct services, including frequency, of both covered and informal/community services • Current measures as well as desired and achieved outcome measures • Member/family strengths (and their intended use) • Review date of the plan (usually 30-90 days) • Discharge Plan (if applicable) • Appropriate signatures and dates (including the member’s, showing he/she accepts the plan) For complete Assessment & Service Plan requirements see Provider Manual Section 3.9 - Assessment and Service Planning Progress notes tie together all the items in the client’s clinical file…

12. Required Documentation: Progress Notes - General Progress notes are a critical component of required documentation. As services are delivered, the clinician or caseworker must keep detailed and accurate records. Information must be in the clinical file to document phone calls, face to face sessions, other provided services and activities, missed appointments, attempts to contact the member/family, etc. Why are progress notes so important? • Encounters with members served yields information for agency billing. • The progress note provides an assessment of the member and family’s status at that moment of contact; notes track progress. • The notes provide a basis for upcoming service planning. • Progress notes provide a record of up-to-the-minute communication for all parties involved with the member/family.

13. Progress Notes - General Progress notes reflect specifics, including: • The member’s/family’s goals. • The therapeutic intervention and specific services provided. • The member’s or family’s response to the intervention/services and progress toward the goals. • The status of the service plan implementation. • Day-to-day changes and progress - or lack of progress. • Objective occurrences/changes in the member’s/family’s life regarding relationships, heath, employment, etc. Some general guidelines for completing all progress notes…

14. Progress Notes - Requirements There are many guidelines for accurate progress note completion - here are some key points… Refer to Provider Manual Section 4.2: Behavioral Health Medical Records Standards. • Include accurate start and stop times for each distinct service provided or activity performed. • Date and sign all entries with date, title and credentials (BHP, BHT, BHPP). Add ‘late entry’ if note is entered after the date the service was provided. • Be sure to document separately each service provided - billable or not - and all activities you perform (phone calls, face-to-face encounters, supervision for/staffing of case, etc.). • Each note must reference the diagnosis, including an indicator that clearly identifies whether the progress note is for a new diagnosis or the continuation of a previous diagnosis. If notes are recorded on paper: use blue or black ink; write legibly; never alter written material - for errors put a single line through the incorrect information, write ‘error’, date and initial - do not erase or cross out!!

15. Progress Notes - Guidelines Be specific, factual and accurate… • Don’t use jargon or highly technical terms. • Spell out abbreviations/acronyms that are not widely known/utilized. • Do integrate member’s words, thoughts or quotes where appropriate. Use quotation marks when quoting member directly. • Use specifics and qualifiers such as “as evidenced by” as appropriate. • Include facts and direct observations. Minimize the use of your impressions and opinions, and when you do utilize these, indicate that they are your opinions and/or impressions. • When referencing another professional, include their full name, title and contact information when indicated. • Use member’s first name in documentation, but do not use other family member names (use father, stepbrother, etc.). Don’t use other client/member names.

16. Progress Notes - Guidelines Additional points to remember when writing progress notes… • Be Objective & Factual • Describe what is observed, not what is assumed. • Avoid interpreting or expressing your opinions. • Document Thoroughly • If it’s not documented, it didn’t happen! • Include specific member responses to, and outcomes of services and activities. • Remember: Encounters/Claims = Billing • Justification for all billed encounters must be documented in the progress note. • See the ADHS/DBHS Covered Services Guideand your agency policies for time documentation. • Split out your non-billable services/activities from your billable services/activities - but be sure to document all services and activities you perform!

17. Progress Notes - Guidelines The key concept of concurrent documentation is a practice that can provide many benefits… Concurrent Documentation is the practice of writing progress notes with the member. The benefits of doing this include: • Being person-centered, helping the member to feel more involved and empowered • Reduces member anxiety/concern about what is being documented • Increases accuracy of documented information • Ensures individualized documentation (not ‘canned’ notes) • Reduces backlog of unwritten notes Concurrent Documentation may not always be possible or practical… use it when you can!

18. Electronic Documentation Many agencies utilize computers to record information, write progress notes, and maintain up-to-date and accurate clinical files. There are some benefits and challenges to electronic documentation: • Benefits: • Easy to maintain the clinical record and to keep the information within neat, in order and accurate • Allows you to easily correct progress notes • Challenges: • Writing progress notes on a computer in front of the member may alienate them, or seem to them disengaging or too clinical • Consider… • Having the member view the screen as you compose the note, providing input/feedback • Jotting notes on paper, then transferring the complete progress note into the electronic file after the member departs

19. Progress Notes Verbiage - Examples Therapeutic intervention Objective observation Courtney participated in Art Therapy for 1 hour this date. She spoke of her drinking while drawing a self-portrait. We discussed strategies to help reduce her drinking. Stella arrived to session 22 minutes late. She was observed to be malodorous and her speech was slurred. Progress toward goals Mikhail provided copy of semester’s grades; received B’s and C’s. Also brought copy of a scholarship of interest. Discussed his goal of utilizing Voc Rehab services to attend New Hope Community College. He said he sees this as a “positive possibility.” Services provided Objective occurrence Picked up and delivered a food box to Sam; transported Sam to appointment with PCP at 3:00pm. John stated he has been hired today at Walton’s Plumbing. He begins work on 06/01/2011.

20. Progress Notes Verbiage - Examples It is important to be as specific as possible… Poor Progress Notes Better Progress Notes Carey cried throughout the 30 minute session. Stated she is “upset” and “unhappy.” Carey seemed upset today. (not clear or factual) Moreno is drinking again. (not clear or factual) Porter was late for his appointment, as usual. He said he overslept. (judgmental / not factual) Lindy complained about Paul and other male staff; she dislikes men. (opinion / not factual) Moreno reported he has drunk to excess the last 5 nights. He stated he has been hung over each morning. Porter arrived 15 minutes late for appointment. Discussed with him that he has been late for last 4 sessions. He reports he has had “problems oversleeping.” Lindy stated, “I feel uncomfortable with Paul and Tim when they lead group.” She says she is “unsure why she feels this way.”

21. Progress Notes - Formats While using a specific progress note format is not mandated by CPSA, we will review 2 common formats for writing progress notes; see your supervisor to find out your agency’s method. Using a format for your progress notes can help you organize the content and increase the focus of the note, while helping to avoid unnecessary information and writing. Format of Progress Notes:SOAP SOAP = Subjective, Objective, Assessment, Plan Format of Progress Notes:DAP DAP = Data, Assessment, Plan Some agencies using the DAP note format combine Subjective and Objective information together under the Data section of DAP

22. Progress Notes - DAP Notes Format of Progress Notes: DAP DAP = Data, Assessment, Plan Data: any general information on the session, issues addressed, member’s situation - that relate to services Assessment: objective measures of the member’s current emotional, symptomatic and/or functioning status Plan: action to be taken by member, staff person, and others to address member needs and goals Includes member self report & your observations/actions; a summary of the main issues presented during the session and the interventions/services provided. Includes member presentation, functional or symptomatic improvement or decline, progress toward goals, responses to interventions, effectiveness of service plan. Includes action steps, next steps, referrals, any refusal of services, outreach & follow up efforts.

23. Progress Note Example: DAP Note Service Plan Goal Addressed: Sala would like to make more friends but gets very anxious when talking to people she doesn’t know. Over the next three months she will practice - at least four times with her case manager - ways to talk with people she doesn’t know. 6/30/11 – (Start Time 1:00pm – Stop Time 2:30 pm) SalaMcKeggan DATA: Engaged Sala in relationship-building exercise at the office from the “How to Make Friends” Program. Sala enthusiastically engaged this worker in role-playing, showing how she would approach someone she’d like to make friends with. Worker modeled for her some other skills/scripts she might want to try. Sala practiced these skills with this worker for almost an hour. ASSESSMENT: Sala appeared to enjoy the exercise/practice, looking much more relaxed at the end of this discussion than when we began. This is the third session we have worked on initiating relationships, and Sala is adding to her socialization skills, as she remembers and utilizes techniques we worked on in previous sessions. Overall her progress in this area is significant, as Sala reports now feeling much more confident in initiating relationships, where three months previous she feels she would “never have even thought about initiating a new relationship”. PLAN: Sala will continue to work on solidifying and expanding her socialization skills, eventually trying out these new skills with individuals with whom she works. Once comfortable with using these skills, this worker will help Sala to generalize these skills to other social situations. This goal will be addressed during our continuing weekly sessions. Tamie Cochrane, BHT 6/30/11 This note supports encountering for the Covered Service ‘Living Skills Training’

24. Progress Notes - SOAP Notes Format of Progress Notes: SOAP SOAP = Subjective, Objective, Assessment, Plan Subjective: the member’s/family’s goals or reasons for accessing services; identifying service plan goal addressed during the encounter; can be recorded in the member’s own words. Objective: the intervention or service provided, the clinician’s observations, including the range of emotions that the member presents. Assessment: the clinician’s opinion of the situation, including progress toward goals and the identification of strengths and improvements and member response to intervention. Plan: the ‘next steps’ to be taken toward the service plan goals, including interventions; include all parties involved and timeframes.

25. Progress Note Example: SOAP Note Service Plan Goal Addressed: In order to remain drug free, Clark will spend at least six hours each week doing positive activities that he enjoys and make him feel better about himself. Clark West 5/30/11 Start: 1:30pm End: 3:00pm Subjective: Worker visited Clark at his home. He identified listening and playing music as one activity that he does instead of doing drugs. He is setting aside an hour or two each day to listen to music, and wants to start playing guitar again. He does not currently have a guitar and wants to save up for one, but reports “it feels almost impossible for me to set money aside for my guitar.” Objective: This worker spent one hour showing Clark how to set up a simple household budget and savings plan using the established agency curricula ‘Simple Budgeting’. Assisted Clark with paperwork to request that $25 of each of his SSI checks be deposited directly into his savings account. Assessment: Clark appears to be committed to not using drugs as evidenced by his willingness and enthusiasm to learn and undertake new behaviors. He appeared to grasp the basics of budgeting as he explained back to this worker the steps he would be required to take each month in order to stick to his budget. Plan: Continue to monitor/support Clark’s budget plan, reinforcing budgeting skills with him as needed. Continue weekly meetings with Clark at his home to ensure support of his positive activities and monitor budget goals. Carleena Middleton, MS, BHT 5/30/11 This note supports encountering for the Covered Service ‘Living Skills Training’

26. Progress Notes - Practice On the next slides, three different sample progress notes documenting member contact/encounters are shown. Review each of these notes, identifying what you consider to be the positive/correct components of each note, as well as any shortcomings or missing components of each note. For reference, compare these samples to the DAP and SOAP progress note examples from the previous slides.

27. Practice - Note 1 7/30/11 Tammy came to meeting today with case manager. She was very angry. We discussed ways to approach her roommate when she wears Tammy’s clothes. • Weaknesses: • No start/stop times. • With no times, how can billable units be determined? • No location of meeting. • No signature, credentials, or date of note. • What goal in the service plan was addressed? • What was the outcome of the discussion w/ Tammy? • How did author know Tammy was angry? Should list observations to support this statement, or use ‘as evidenced by…’. • Is this a billable service? If so, what service was provided? • No diagnosis referenced. • No DAP or SOAP format evident; no indication of a ‘Plan’ (what happens next). • Strengths: • Date of the meeting documented. • ????.... a very poor note

28. Practice - Note 2 4/1/12 1:00-2:30pm Mtg. w/ C.R. Mo. in wtg. rm. Not DTS/DTO. Followed-up w/ Paul, he’ll sit in for next med. appt. Called Mo. later and told her. • Strengths: • Date and start/stop times documented. • ????.... again, a very poor note. • Weaknesses: • Too many abbreviations. • Followed up w/ Paul regarding what? • Who is the client? • Who is not DTS/DTO? C.R.? Mo.? And this is as evidenced by what? • What goal in the service plan was addressed? • Is this a billable service? If so, what service was provided? • The note does not at all describe how the billed 90 min. was utilized. • ‘Called Mo. later’ is Case Management - this is a different service so it needs to be documented in a separate note. • No signature, credentials, or date of note. • No diagnosis referenced. • No DAP or SOAP format evident.

29. Practice - Note 3 3/9/12 10:00-10:30 a.m. Member came to appointment with case manager. He said that he will be hanging out with his friends this weekend. Member stated he spoke with his cousin on the phone this morning, they decided the cousin will go out with client and his friends this weekend. At first he could not think of anything he would like to do but decided he would go to a car show at Reid Park. Member talked about his favorite kind of car, stated that he likes Toyotas, “They are reliable and have good engines, but I don’t think there will be one at the car show”. I listened and acknowledged that client was able to connect with friends and his cousin. Member also discussed feeling happy that he will meet with the Vocational Specialist because he is ready to work. He was giddy with excitement like a kid, and reported, “I can’t wait to have a paycheck again!” Fred Jones, BHT 3/9/12 (See next slide for discussion)

30. Practice - Note 3 (Discussion) 3/9/12 10:00-10:30 a.m. Member came to appointment with case manager. He said that he will be hanging out with his friends this weekend. Client stated he spoke with his cousin on the phone this morning, they decided the cousin will go out with client and his friends this weekend. At first he could not think of anything he would like to do but decided he would go to a car show at Reid Park. Client talked about his favorite kind of car, stated that he likes Toyotas, “They are reliable and have good engines, but I don’t think there will be one at the car show”. I listened and acknowledged that client was able to connect with friends and his cousin. Client also discussed feeling happy that he will meet with the Vocational Specialist because he is ready to work. He was giddy with excitement like a kid, and reported, “I can’t wait to have a paycheck again!” Fred Jones, BHT 3/9/12 • Weaknesses: • No location of meeting. • Did not use member’s first name. • What goal in the service plan was addressed? • Difficult to determine which billable service (if any) was provided. • Too much detail was included about things not pertinent to treatment (social plans; favorite type of car). • Little information documented regarding employment (which probably is a service plan goal). • Note did not list the name, agency or contact information of the Voc. Spec. (collateral contact). • No diagnosis referenced. • No DAP or SOAP format evident; no indication of a ‘Plan’ (what happens next). • Strengths: • Date and start/stop times documented. • Signature, credentials, date of note present. • Client quotes utilized - though quotes do not seem to pertain to treatment or service goals.

31. Progress NotesFinal Points to Remember • Include and support: • what covered service was provided • what skills the client demonstrated • client responses to interventions/services • your and other staff interactions and interventions • what progress has been made re: goals/needs/objectives • on the service plan • Be objective and factual • Note should relate to the service plan and services provided • Collateral contacts - provide all information • Avoiding judgmental and flowery language Remember… If it isn’t documented, then it didn’t happen! There is a system in place that reviews member records for proper clinical documentation…

32. ADHS/DBHS and CPSAData Validation What are the major items/specifics these Data Validation studies focus on?… • Data Validation studies/audits are performed by CPSA to identify problems and educate providers in order to reduce visits by CPSA’s Compliance Departmentand the ADHS/DBHS Office of Program Integrity (OPI). • Data Validation studies are performed to determine the quality of the corresponding documentation for member encounters. (encounter = billable service) • Data Validation Studies are done quarterly for the CSPs and semi-annually for Subcontractors.

33. Documentation: Data Validation The progress note must contain a complete and accurate description of covered services provided in the encounter, supporting the definition of the service encountered for, per the Covered Services Guide service definitions. Data ValidationStudies = Information in the clinical record/progress notes is compared with other submitted encounter data: • The comparison should show that covered services are documented/encountered: • In a timely manner • Completely (no omissions) • Correctly

34. Documentation: Data Validation • Areas of Review: • Timeliness - claims must be submitted to CPSA within 45 days for CSPs or Direct Contract Providers & 90 days for Subcontractors (See Provider Manual Section 6.2 - Submitting Claims and Encounters to the RBHA for specific guidelines). For Fee for Service - 180 days clean claim status effective: 07/01/11. • Omissions - all documented services are billed/encountered and documentation exists in the chart for an encounter sent to CPSA. • Correctness - information accurately represents the services provided: • date of service (inaccurate date of service can cause omissions) • service/billing code (HCPC or CPT) • place of service (11, 12, 99 other – must specify location where service was provided) • modifier (HN vs. HO) reimbursement is affected • member’s diagnosis code (taken from the applicable assessment if the note is not written by someone qualified to diagnose) • number of billable units (determined from your service start and stop times) There are some ‘risk areas’ where Data Validation errors commonly occur…

35. Documentation: “Risk areas” • Documentation is incomplete, insufficient and/or illegible. • Progress note does not detail/support the services provided/billed for. Hint: use Covered Services Guide service code description verbiage (i.e. - taught, demonstrated, assisted) to help support documentation and service billed. • Failure to include in note reason for encounter, history, findings, clinical impression, plan of care, date and identity of observer/author. • No rationale provided for ordering diagnostic or ancillary services (labs, x-rays, etc…). • CPT, HCPC and ICD-9 (billing) codes not supported by record - service does not support diagnosis or service plan goals. • Health risk factors not identified. Our last module topic - fraud and abuse relating to documentation…

36. Fraud and Abuse Documentation fraud is serious, against the law, and can result in fines, sanctions, or criminal action against you and/or your agency. Fraud and abuse is an important issue in all aspects of our daily work duties and responsibilities. Fraud and abuse can occur around documentation and other record-keeping practices.

37. Fraud and Abuse: Defining Fraud Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes Fraud under applicable Federal or State law.

38. Applicable Laws & Regulations • 31 USC § 3729- 3733 False Claims Act • A.R.S. 13-2311 Fraudulent Schemes and Practices • A.R.S. 36-2918 Medicaid False Statements • A.R.S. 36-2918.01 Duty to Report Fraud and Abuse • A.A.C. R9-22-101 Civil Monetary Penalties & Assessments

39. Fraud and Abuse: Examples… Examples of fraud and abuse… • Falsification of clinical documentation (i.e., a licensed therapist documented in the medical record that a member had been seen multiple times for therapy. In fact, the member was not seen). • Intentionally using incorrect billing codes; Billing for non-covered services; Misrepresentation of services. • Alteration of a claim or progress note; Double billing; False data submitted. • Inadequate or missing documentation resulting in denied claims. • Services provided by unqualified providers. • Administrative/Financial Actions that include the following: • Kickbacks • Falsifying credentials • Fraudulent enrollment practices

40. Fraud and Abuse: Defining Abuse Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the Medicaid program, or in reimbursement for services that are not medical necessary.

41. Fraud and Abuse: Examples… More examples of fraud and abuse… • Unsigned documentation and assessments (inconsistencies) • Personal purchases on the company credit card • Theft of inventory items • Theft of cash from deposits • Falsifying time card with time not worked • Using company vehicle for personal use • Using company phone for personal calls • Wasteand wasteful practices are now being scrutinized. Waste: Spending that can be eliminated, including over-utilization of services, without reducing quality of care.

42. Fraud and Abuse: Taking Action If you know or, or even suspect fraud and/or abuse are being committed at your agency, you are required to report this. First contact your supervisor OR your supervisor’s supervisor. You may also talk with your Human Resources Department or your Compliance Officer. If these avenues are inappropriate for your situation, you may also call: • CPSA Fraud & Abuse Hotline: 520-318-6964 • ADHS/DBHS Fraud & Abuse Hotline: 866-569-4927 • AHCCCS Office of Inspector General: 888-487-6686 All of these calls can be made anonymously.

43. Documentation… In Conclusion • Remember, good clinical documentation is an important part of successful treatment. • Practice concurrent documentation when you can. • Use a structured format as your guide in writing progress notes. • \ • Ensure services provided are relevant for the member’s diagnosis and needs. • Make sure your progress note supports the services provided and encountered for. Still have questions? Please ask your clinical supervisor. They can help you learn the protocols of your agency and provide you guidance and feedback. You can also find answers to your documentation questions in the appropriate Provider Manual sections.…

44. Documentation: The Provider Manual A great source for learning more about accurate and proper documentation is the Provider Manual… Standards for documentation are listed in detail in Provider Manual Section 4.2 ‘Behavioral Health Medical Records Standards’ For complete Assessment and Service Plan requirements see Provider Manual Section 3.9 ‘Assessment and Service Planning’ For more information regarding Fraud & Abuse refer to Provider Manual Section 7.1’Fraud & Program Abuse Reporting’ When documenting Covered Services in progress notes, and for billing requirements, refer to the ADHS/DBHS Covered Services Guide: The ADHS/DBHS Covered Services Guide is online here: http://www.azdhs.gov/bhs/pdf/CovBHsvsGuide.pdf

45. Documentation…In Conclusion Documentation is vitally important - doing it correctly is a critical part of your job. Thank you for your time and attention. Please complete the Post Test/Final Exam at this time.