Clinical
Procedures

Verbal
Notification

CPRP

Forensic
Aftercare

Authorization

Documentation  

Progress
Notes and
Progress
Notes
Instructions

mGAF
Scale

AIMS

Medications

Formulary

Medication
Assistance

Benzodiazepines

Antipsychotics

Lab
Services

Authorization
Form

Claims
Processing

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