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Third-party reviewers can examine all clinical records. BJCBH staff may periodically audit clinical records. Contract providers must include this information when submitting to BJCBH and maintain a copy for themselves.
Progress Notes -- Basic Requirements
First Note of the Year on All BJCBH Clients
Should contain all progress note elements and include:
- Diagnoses for Axis I-V
- Complete list of current medications and dosages
- Allergies
Progress Note
Elements include:
- Date
- Start time
- Total time devoted to the patient's care/(total elapsed time)
- Patient name and identifiers
- Date of Birth (DOB)
- BJCBH ID number
- Interim history, including current response to treatment
- Pertinent medical and psychiatric findings
- Side effects
- Mental status exam elements
- New diagnoses
- Changes in diagnosis
- Current medications (may be on a prescription log)
- Other treatment plan items
- Legible note
- Identifiable signature; a signature card may be provided for HIMS to verify signatures
First Note on a New Patient
Full psychiatric evaluation including:
- Diagnoses for Axis I-V
- Treatment plan
- Prescribed medications, dosages and allergies
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