Outpatient Specialty

Mental Health Services

Clinical Staff

Clinical Documentation
Manual
2022

California Mental Health Services Authority (CalMHSA)

 TABLE OF CONTENTS

Table of Contents
Introduction To This Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Health Care Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Medi-Cal Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Mental Health Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Managed Care Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Criteria for Access to Specialty Mental Health Services (SMHS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Overview of criteria for adults aged 21 year and older . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Overview of criteria for persons under 21 years of age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Screening Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Standardized Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Assessment Domains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Presenting Problem/Chief Complaint (Domain 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Trauma (Domain 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Behavioral Health History: (Domain 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Medical History and Medications: (Domain 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Psychosocial Factors: (Domain 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Strengths, Risk and Protective Factors (Domain 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Clinical Summary, Treatment Recommendations, Level of Care Determination (Domain 7) . . . . . . . . . . . . . . 14
The Problem List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Care Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Stages of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Treatment Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Treatment Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Co-Occurring Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Care Transitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Claiming for Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Appendix I: Acronym List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Appendix II: Medi-Cal Plans by Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Appendix III: Sample Progress Note Treatment Plan Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Appendix IV: Scope of Practice Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Appendix V: DHCS Priority SDOH Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Appendix VI: Sample Progress Note Narratives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Plan Development/Progress List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Individual Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Individual Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Collateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Appendix VII: Documentation Manual Change Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

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Introduction to this manual

The California Medi-Cal system is undergoing a significant transformation to reform the
program in service of improving the quality of life and health outcomes of Medi-Cal members.
This person-centered approach, operationalized by the Department of Health Care Services
(DHCS), through its California Advancing and Innovating Medi-Cal (CalAIM) initiative,
streamlines processes and documentation in order to better address the needs of persons in
care while improving access to and coordination among the delivery systems responsible for
providing care. DHCS aims to provide Californians with access to equitable, integrated, cost-
effective and high-quality health care.
The intent of this documentation manual is to support the implementation of DHCS guidance
concerning beneficiary care coordination efforts between the Mental Health Plan (MHP) and
Managed Care Plan (MCP) services delivery systems (e.g. screening, transition of care and
service referrals), and the essential documentation requirements for specialty mental health
services for clinical documentation and claims reimbursement. Specifically, this manual
provides guidance to Licensed Practitioner of the Healing Arts (LPHA)1 staff in an MHP setting
that claims outpatient Medi-Cal services. This documentation manual will cover many relevant
topics and concepts that support your work with children, youth, adults, and families. The
audience for this manual includes both those licensed, registered and waivered practitioners
who are new to documentation of services, as well as those practitioners who have experience
with pre-CalAIM documentation standards. Aligned with CalAIM, readers will note the use of
person-centered language, the focus on clinical treatment and a trauma-informed lens as
key elements of the manual. For example, individuals receiving treatment will be referred to as
“people” or “people in care”, rather than “clients”, “patients”, or “beneficiaries”.

Health Care Systems

Health care systems are intended to help people improve or maintain their health and wellness
within their community. For this to happen, people need to have the ability to access not just
physical health care but quality behavioral health care in a way that is responsive to their
particular needs and situation, respects their choices and authentically centers their voice.
We know from research that care is not always accessible, available, or responsive in an
equitable way. Research further shows that access to and engagement in quality health care
is affected by a number of factors, including race, ethnicity, socioeconomic status, and other
social determinants. Social determinants of health (SDOH) play a huge part in people’s health
and wellness. SDOH are the conditions in the environments where people are born, live, learn,
work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life
outcomes and risks. SDOH are grouped into five domains (CDC)2:

1. Economic stability (ability to access and maintain food, clothing, shelter, and mobility as
well as other basic needs within their community)
2. Education (opportunities to learn and build skills)
3. Health care access and quality (to prevent and treat illness and injury)
1 “Licensed Practitioner of the Healing Arts” in this context means licensed, registered or waivered psychologists, clinical
social workers, marriage and family therapists or professional clinical counselors. Psychiatrists and nurses are also LPHAs;
however, they have different scopes of practice.
2 Social Determinants of Health | CDC; Healthy People 2030, U.S. Department of Health and Human Services, Office of Dis-
ease Prevention and Health Promotion. Retrieved [May 22], from https://health.gov/healthypeople/objectives-and-data/
social-determinants-health

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4. Neighborhood and built environment (safe, free from pollutants and access to nature)
5. Social and community context and connectedness
SDOH contribute to health disparities and inequities simply by limiting access to fundamental
resources aimed at supporting health and wellness. For example, if behavioral health services
are offered in one part of town that is difficult to get to, those who live far away or have
transportation challenges may not receive the services they need in a timely fashion. Or perhaps
the same clinic does not employ direct service staff who speak the language or understand the
culture of the person seeking care. This again impacts a person in care’s ability to access care
that meets their individualized needs. Lastly, we have witnessed the harsh realities of inequities
revealed by the COVID-19 pandemic, with stark differences in outcomes including mortality seen
along racial/ethnic lines, socioeconomic status, and educational attainment3.
Although there are efforts aimed at addressing health disparities, there is still a lot of work to be
done. As practitioners, we have a responsibility to look within our organizations and advocate
for changes that help reduce or eliminate disparities within health systems. Through this diligent
attention, systems can transform to best meet the needs of the people they are intended to
serve. One of the monumental ways that CalAIM supports our systems in addressing health
disparities is in the acknowledgement of the impact of trauma on health and wellness. We
are able to streamline access to service, especially for youth, when they are found to be at
high risk for a mental health disorder due to the experience of trauma, either by completion
of a sanctioned trauma screening tools or by other identification of involvement in the child
welfare system, juvenile justice system or homelessness. Details on this access criteria will be
addressed later in this manual, as it cues practitioners in the way that treatment services can
be initiated while assessment is occurring concurrently.

3 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786466

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Medi-Cal Programs
In California, the Department of Health Care Services (DCHS) is the state agency responsible
for the administration of the state’s Medicaid program. In California, we refer to Medicaid as
“Medi-Cal.” The Medi-Cal program is a mix of federal and state regulations serving over 13
million people, or 1/3 of all Californians. Medi-Cal covers 40% of children and youth and 43% of
individuals with disabilities in California.4

Medi-Cal behavioral health services are “carved out”, meaning that they are delivered through
separate managed care delivery systems, each of which is responsible for delivering different
sets of services to individuals depending on their care needs.

To keep it simple, we will look at the three managed care plans; Mental Health Plans (MHP)
operated by county behavioral health departments, Drug Medi-Cal Plans (DMC or DMC-ODS)
administered respectively by the state or the county, and Managed Care Plans (MCP) physical
healthcare plans. The MCPs, which are operated by either publicly run or commercial entities,
also administer the Non-Specialty Mental Health Services (NSMHS)benefit.

County State
MCP MCP MHP DMC-ODS/DMC Dental

Specialty Substance Use

Physical Non-Specialty
Mental Health Treatment Dental
Healthcare Mental Health
Services

Mental Health Plans

Specialty Mental Health Services (SMHS) are managed locally by county Mental Health Plans
(MHPs). Fifty six county MHPs are contracted with DHCS to administer the Medi-Cal SMHS benefit.
In addition to managing the benefit, MHPs directly deliver and/or contract with Community-
Based Organizations (CBOs) or groups/individual providers to deliver an array of services
designed to meet the needs of individuals with Medi-Cal who have significant and/or complex
care needs. This array includes highly intensive services and programs, including therapy,
community-based services, wraparound, and intensive case management programs. (See
Appendix II for a list of covered services.)
SMHS are provided to persons with mental health conditions that requires intervention to
support the person’s ability to safely participate in their communities and achieve wellbeing.
The Medi-Cal populations served by county MHPs include elderly, disabled, adults, youth and
foster or probation youth below federal poverty levels with mental health conditions or trauma
significantly impairing their ability to successfully participate in their communities. In short,
MHPs serve some of the most vulnerable populations.

Drug Medi-Cal and the Drug Medi-Cal Organized Delivery System

Within the broader Medi-Cal program, DHCS administers the Drug Medi-Cal (DMC) Program.
DMC reimbursement is issued to counties and direct providers that have a contract with

4 https://www.chcf.org/publication/2021-edition-medi-cal-facts-figures/

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DHCS for approved DMC services provided to Medi-Cal beneficiaries. Persons in care who are
eligible for DMC services include individuals eligible for federal Medicaid, for whom services
are reimbursed from federal, state, and/or county realignment funds. Such services include
Narcotic Treatment Program (NTP), Outpatient Drug Free (ODF) individual and group, Intensive
Outpatient (IOP), Perinatal Residential and Naltrexone Treatment. In order for Drug Medi-Cal
to pay for covered services, eligible Medi-Cal members must receive substance use disorder
(SUD) services at a Drug Medi-Cal certified program.
Drug Medi-Cal – Organized Delivery System (DMC-ODS) is a program for the organized delivery
of substance use disorder (SUD) services to Medi-Cal-eligible individuals with SUD residing in
a county that has elected to participate in the DMC-ODS.5 Counties participating in the DMC-
ODS program provide their resident Medi-Cal beneficiaries with a range of evidence-based
SUD treatment services in addition to those available under the Drug Medi-Cal (DMC) program.
Critical elements of DMC-ODS include providing a continuum of care modeled after the
American Society of Addiction Medicine (ASAM) Criteria® for SUD treatment services, increased
local control and accountability, greater administrative oversight, creation of utilization controls
to improve care and efficient use of resources, evidence-based practices in substance use
treatment, and increased coordination with other systems of care. To receive services through
the DMC-ODS, a beneficiary must be enrolled in Medi-Cal, reside in a participating county, and
meet the criteria for DMC-ODS services.

Managed Care Plans

Managed Care Plans (MCPs) are responsible for the majority of medical (physical health care)
benefits and NSMHS for individuals. The MCPs provide mental health services to those with less
significant or complex care needs, so may provide lower frequency/intensity of mental health
services. MCPs cover medication evaluation and treatment, group and individual therapy,
psychological testing and long-term skilled nursing services as well as prescription medications,
including psychotropic medications (See Appendix II for a list of covered services). There are 24
MCPs across 58 counties delivering services across a managed network of providers (individual
professionals or agencies). Some counties may have multiple MCPs in one county and
individuals with Medi-Cal can choose which MCP they would like to belong to. In other counties,
there may be a single MCP providing coverage to all individuals with Medi-Cal. To find out which
MCPs provide coverage in your county, check the DHCS website, linked here for convenience.
All three plan types discussed here - MHPs, DMC State Plan/DMC-ODS and MCPs administer
and deliver an array of services to Medi-Cal members. Given the complexity of the systems, it
can be difficult for individuals seeking services to understand which plan would best treat their
behavioral health care needs and where/how to access SMHS, DMC or NSMHS. CalAIM provides
new guidelines for accessing medically necessary care.

Definition of Medical Necessity

All Medi-Cal services provided to persons in care need to meet the standard of being
“medically necessary”. The definitions of medical necessity are somewhat different, based
upon the age of the person in care. For individuals age 21 and older, a mental health service
is considered “medically necessary” when it is “reasonable and necessary to protect life, to
prevent significant illness or significant disability, or to alleviate severe pain.” For individuals
under age 21, the definition of whether a mental health service is considered “medically
5 42 CFR 438.2 https://www.law.cornell.edu/cfr/text/42/438.2 or 42 CFR 438.14 https://www.law.cornell.edu/cfr/text/42/438.14,
respectively

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necessary” falls under the Early and Period Screening, Diagnostic and Treatment (EPSDT)
Services language under a specific section of Title 426. This section requires provision of all
Medicaid (Medi-Cal) coverable services necessary to correct or ameliorate a mental illness or
condition discovered by a screening service, whether or not the service is covered under the
State Plan. These services need not be curative or restorative, and can be delivered to sustain,
support, improve or make more tolerable a mental health condition.

Access to the Specialty Mental Health Services (SMHS) System

In a previous section, we described covered services under the MHP Medi-Cal benefit. Next, we
will discuss the criteria for accessing specialty mental health services (SMHS) through the MHP.
While we will be discussing the technical criteria, we encourage practitioners to continue to
review the information from the perspective of the person in care with empathy and centering
the person’s voice regarding their health care decisions.
The criteria we will discuss in this section are for two distinct age cohorts: individuals aged
21 years and older and individuals under 21 years of age. Each of these cohorts have distinct
criteria due to their developmental needs.7 It is important to point out early that a person may
begin to receive clinically appropriate services, so long as the person would benefit from the
SMHS services, even before a diagnosis has been fully articulated and a final determination has
been made.

Overview of criteria for persons aged 21 years and older

• The person has a significant impairment in social, occupational, or other important

life activities and/or there is reasonable probability of significant deterioration in an
important area of life functioning
• AND the significant impairments listed above are due to a mental health disorder,
Diagnostic Statistical Manual, Fifth Edition (DSM-5), either diagnosed or suspected,
but not yet diagnosed.

Overview of criteria for persons under 21 years of age

• The person is experiencing homelessness, and/or is interacting with the child welfare
or criminal justice system
• OR has scored high on the trauma screening tool, placing them at high risk for a
mental health disorder.8
• OR, the person has a significant impairment, a reasonable probability of significant
deterioration in an important area of life functioning, a reasonable probability of not
progressing as developmentally appropriate, or there is no presence of impairment
• AND the significant impairments listed above are due to a mental health disorder,
Diagnostic Statistical Manual, Fifth Edition (DSM-5), either diagnosed or suspected,
but not yet diagnosed.

6 Title 42, Section 1396d(r)(5) https://www.law.cornell.edu/uscode/text/42/1396d

7 DHCS Behavioral Health Information Notice (BHIN) No: 21-073
8 Specific information on the trauma screening tools, scoring and thresholds for access criteria will be provided by DHCS at
a later date

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Care Care
Screening Assessment Problem List Treatment Discharge
Coordination Transitions

Screening Tools
Persons needing care may access care in several different ways including self-referral, getting
a referral from another behavioral health practitioner, or a primary health care provider, etc. No
matter how a person initiates care, the person can expect to receive timely mental health services
whether from an MHP or through the MCP. If we keep the person’s care needs at the forefront of
treatment decisions, there is no wrong door by which the person may enter. The goal is to ensure
that individuals seeking care have access to the right care in the right place at the right time,
regardless of what door they come to initially.
Screening is used as the first step in getting the person connected with the right care in the
system. Screening may or may not be completed by an LPHA. When an individual seeks care,
the standard “Screening Tool” is used to understand the person’s needs and get them to the
provider that best matches their needs. The screening tools may be completed in person,
by phone, or in a community setting. The screening tools do not replace the need for an
assessment, which will come later. The screening tools, one for individuals under the age of 21
(youth) and one for individuals over the age of 21 (adult), are used to help identify behavioral
health needs, symptoms, and distress.
These screening tools are intended to be used by the MHP and MCP service delivery systems by
a diverse workforce and were designed for use by non-clinical staff (e.g., Access lines, hotlines,
intake staff) to determine the best place for a person to start care (MCP, MHP, or SUD delivery
system). The screening tools are intentionally brief, as they are completed in one encounter
in order to determine which service delivery system is a more appropriate fit. In instances
where serious risk factors are identified (danger to self, danger to others, etc.), the individual
administering the tool is expected to immediately contact appropriate staff within their MHP (or
emergency services if warranted) to conduct a more in-depth risk evaluation, including crisis
supports.
Once the screening tool has been administered, there may be a referral for an assessment
by an LPHA to develop a clinical understanding regarding the person’s care needs, including
diagnosis, and to confirm the appropriate
treating system and what services are medically
necessary. Because humans are complex, the
assessment may take more than one session
to fully determine the overall care needs. For
many individuals and/or in some circumstances,
assessment also includes the collection of
information from collateral sources including,
but not limited to, family members, prior service
providers and/or system partners. While the
assessment is in process, the person in care
may also receive clinically appropriate services
simultaneous to the assessment services.
Clinically appropriate services include prevention,
screening, assessment, and treatment services
(e.g., therapy, rehabilitation, collateral, case
management, medication support) and are

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 CLINICAL DOCUMENTATION MANUAL

covered and reimbursable under Medi-Cal even when9:

1. Services are provided prior to determination of a diagnosis or prior to determination of
whether SMHS access criteria are met;
• While a mental health diagnosis is not a prerequisite for access to covered
services and while a person may access necessary services prior to determining
a diagnosis, a provisional diagnostic impression and corresponding ICD-1010 code
must be assigned to submit a service claim for reimbursement. There are ICD-
10 codes LPHAs may use prior to the determination of a diagnosis – if there is a
suspected disorder within the LPHA’s scope, “Other Specified” or Unspecified” ICD-
10 codes are available. Additionally, the code Z03.89 “Encounter for observation for
other suspected diseases and conditions ruled out” may be used.
• As appropriate, LPHAs and non-LPHAs alike may use ICD-10 codes Z55-Z65
“Persons with potential health hazards related to socioeconomic and psychosocial
circumstances11.
2. The person in care has a co-occurring mental health condition and substance use
disorder (SUD), even when the SUD diagnosis is later determined to be the primary
diagnosis; or
3. Services are provided concurrently with other delivery systems when coordinated and
non-duplicative.
• In instances when a person is receiving or requires services from another delivery
system, MCP or DMC/DMC-ODS delivery systems, the person may receive services
from multiple delivery systems so long as the services are coordinated and not
duplicative. In short, a person may receive or continue to receive services from
multiple delivery systems but only through thoughtful care coordination amongst
providers and for services covered by each of the delivery systems.
• For example, if a person accesses care through the MHP and it is determined the
person would also benefit from care through the DMC/DMC-ODS system to treat
a substance use condition, the MHP would be expected to coordinate with the
DMC/DMC-ODS provider to ensure services are not duplicative. In keeping with this
example, if the person was already receiving therapy services through the MCP
and did not want to change therapists, the person may continue to receive therapy
through the MCP, while receiving other coordinated services through MHP and
DMC/DMC-ODS systems, so long as
they are not duplicative. Again, in this scenario, where persons in care are receiving
needed services from multiple delivery systems, coordination of care is critical.
We should note that the responsibilities for covered services by each of the service delivery
systems remains in place, with each delivery system responsible for providing covered services
per its contract with DHCS. This remains true even when persons in care are receiving services
from multiple delivery systems, as each delivery system has separate and distinct services for
which it provides coverage.

9 Welfare & Institutions Code 14184.402(f)

10 https://www.dhcs.ca.gov/Documents/BHIN-22-013-Code-Selection-During-Assessment-Period-for-Outpatient-Behav-
ioral-Health.pdf and https://www.cms.gov/medicare/icd-10/2022-icd-10-cm
11 https://www.dhcs.ca.gov/Documents/BHIN-22-013-Code-Selection-During-Assessment-Period-for-Outpatient-Behav-
ioral-Health.pdf and https://www.cms.gov/medicare/icd-10/2022-icd-10-cm

9
 CLINICAL DOCUMENTATION MANUAL

Care Care
Screening Assessment Problem List Treatment Discharge
Coordination Transitions

Standardized Assessment
The goal of an assessment is to understand the person’s needs and circumstances, in order
to recommend the best care possible and help the person recover. The assessment must be
completed under the guidance of an LPHA. The assessment evaluates the person’s mental health
and well-being and explores the current state of the person’s mental, emotional, and behavioral
health12 and their ability to thrive in their community. An assessment may require more than one
session to complete and/or may require the practitioner to obtain information from other relevant
sources, referred to as “collateral information”, such as previous health records or information
from the person’s support system to gather a cohesive understanding of the person’s care
needs. Services to support the person’s ability to remain safe and healthy in the community are
of utmost importance. Therefore, it is important that practitioners ensure that the assessment
process begins with risk and safety discussions, then moves on to discuss other matters of
urgency to the person in care and completes assessment activities by gathering background
information that impacts the primary concerns of the person in care.
Many different tools or tests are available to assess different aspects of a person’s functioning,
such as tools to assess trauma, depression, suicide risk, and mental status. While the use
of tools is often left to the discretion of the assessing practitioner, it is the practitioner’s
responsibility to use the tool for its intended purpose and to have the appropriate training for
administration and scoring of the tool. Information or results from the tools utilized should be
included as part of the assessment.
DHCS requires practitioners to complete an assessment for the determination of behavioral
health needs. While all persons shall receive a mental health assessment to best determine
their individual needs, there are different assessments to meet this requirement, based on age
and type of service being sought.
• Assessments for mental health services for adults aged 21 years and older shall cover all
the domains listed in the section below.
• Assessment for mental health services for persons under the age of 21 years old shall
include the Children and Adolescent Needs and Strengths (CANS-50) and Pediatric
Symptom Checklist (PSC-35) in addition to the domains listed in the section below.
• Assessments for substance use disorders for persons of all ages shall use the American
Society of Addiction Medicine (ASAM) criteria when determining level of care.
Central to the completion of a comprehensive assessment is collaboration with the person in
care. Centering the voice of the person in care and remaining curious and humble about the
client’s experiences, culture and needs during the assessment process is crucial to building this
collaboration. When assessments are conducted in this manner, they function as an important
intervention and relationship building opportunity. Focusing on strengths, culture, and resiliency,
in addition to challenges, creates a setting where the person in care feels seen as a whole
person. Assessments must be approached with the knowledge that one’s own perspective is
full of assumptions, so that clinicians maintain an open mind and respectful stance towards the
person in care.
Curiosity and reflection indicate humility and a deep desire to truly understand the person
12 California Code of Regulations, Title 9, Chapter 11, Section 1810.204

10
 CLINICAL DOCUMENTATION MANUAL

in care and to help them meet their needs. A key outcome of the assessment process is the
generation of shared agreement on the strengths and needs of the person in care, as well as
how to best address those needs. The assessment process generates a hypothesis, developed
in collaboration with the person in care, that helps to organize and clarify service planning.

Standardized Assessment Requirements (Including Timeliness)

A. SMHS
a. MHPs shall require providers to use uniform assessment domains as identified below. For
beneficiaries under the age of 21, the Child and Adolescent Needs and Strengths (CANS)
Assessment tool may be utilized to help inform the assessment domain requirements.
b. The time period for providers to complete an initial assessment and subsequent
assessments for SMHS is up to clinical discretion; however, providers shall complete
assessments within a reasonable time and in accordance with generally accepted
standards of practice.
c. Services provided prior to determination of a diagnosis, during the assessment, or prior
to determination of whether NSMHS or SMHS access criteria are met are covered and
reimbursable, even if the assessment ultimately indicates the beneficiary does not meet
criteria for SMHS.
d. The assessment shall include a typed or legibly printed name, signature of the service
provider and date of signature.
e. The assessment shall include the provider’s recommendation – and determination of
medical necessity for services. The problem list and progress note requirements identified
below shall support the medical necessity of each service provided.
f. The diagnosis, Mental Status Exam (MSE), medication history, and assessment of relevant
conditions and psychosocial factors affecting the beneficiary’s physical and mental
health must be completed by a provider, operating in their scope of practice under
California State law, who is licensed, registered, waivered, and/or under the direction of a
licensed mental health professional as defined in the State Plan13.
g. The Mental Health Plan (MHP) may designate certain other qualified providers to
contribute to the assessment, including gathering the beneficiary’s mental health and
medical history, substance exposure and use, and identifying strengths, risks, and barriers
to achieving goals14.

Assessment Domain Requirements15

The assessment contains universally-required domains that should not vary from MHP to MHP
or CBO to CBO. Below is information on the standardized domains comprising the assessment
for understanding the person’s care needs. While each of the domains are required and must
be addressed, information may overlap across domains. When conducting an assessment, it
is important to keep in mind the flow of information and avoid duplication to ensure a clear
and ideally chronological account of the person’s current and historical need is accurately
documented. Include the perspective of the person in care and, whenever possible, use their
13 https://www.dhcs.ca.gov/formsandpubs/laws/Documents/Supp1toAtt3.1-A98-16%20(10-012B).pdf
14 https://www.law.cornell.edu/regulations/california/9-CCR-Sec-1840-334#:~:text=Code%20Regs.-,Tit.,Services%20Con-
tact%20and%20Site%20Requirements&text=(a)%20Crisis%20Residential%20Treatment%20Services,be%20delivered%20
at%20that%20site; https://www.dhcs.ca.gov/formsandpubs/laws/Documents/Supplement_3_to_Attachment_3.1-A.pdf;
https://www.dhcs.ca.gov/Documents/Supplement-2-to-Attachment-3-1-B-2-4-22.pdf
15 WIC 14184.402(c) and 402(d)

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 CLINICAL DOCUMENTATION MANUAL

quotes within the document.

Below are the domain categories, key elements, and guidance on information to consider
under each domain. The information in the outline below is not meant to be an exhaustive list.
The practitioner should always consider the person within the context of their developmental
growth and their larger community, including cultural norms or expectations when completing
and documenting an assessment. Information within the assessment should come from the
person seeking care, in their own words whenever possible. Particularly for children/youth and
those with disabling impairments, this may also include information from collateral sources.

Presenting Problem/Chief Complaint (Domain 1)

Domain 1 focuses on the main reason the person is seeking care, in their own words if
appropriate. The goal is to document an account of what led up to seeking care. This domain
addresses both their current and historical states related to the chief complaint.
· Presenting Problem (Current and History of) –The person’s and collateral sources’
descriptions of problem(s), history of the presenting problem(s), impact of problem on
person in care. Descriptions should include, when possible, the duration, severity, context
and cultural understanding of the chief complaint and its impact.
· Current Mental Status Exam – The person’s mental state at the time of the assessment.
· Impairments in Functioning - The person and collateral sources identify the impact/
impairment – level of distress, disability, or dysfunction in one or more important areas of
life functioning as well as protective factors related to functioning.

Trauma (Domain 2)

Domain 2 involves information on traumatic incidents, the person in care’s reactions to trauma
exposures and the impact of trauma on the presenting problem. It is important that traumatic
experiences are acknowledged and integrated into the narrative. Take your cues from the
person in care — it is not necessary in every setting to document the details of traumatic
incidents in depth.
· Trauma Exposures – A description of psychological, emotional responses and
symptoms to one or more life events that are deeply distressing or disturbing. This can
include stressors due to significant life events (being unhoused or insufficiently housed,
justice involvement, involvement with child welfare system, loss, etc.)
· Trauma Reactions – The person’s reaction to stressful situations (i.e., avoidance of
feelings, irritability, interpersonal problems, etc.) and/or information on the impact of

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trauma exposure/history to well-being, developmental progression and/or risk behaviors.

· Trauma Screening- The results of the trauma screening tool to be approved by DHCS
(e.g., Adverse Childhood Experiences {ACEs}), indicating elevated risk for development of
a mental health condition.
· Systems Involvement – The person’s experience with homelessness, juvenile justice
involvement, or involvement in the child welfare system.

Behavioral Health History (Domain 3)

Domain 3 focuses on history of behavioral health needs and the interventions that have
been received to address those needs. Domain 3 also includes a review of substance use/
abuse to identify co-occurring conditions and/or the impact of substance use/abuse on the
presenting problem.
· Mental Health History – Review of acute or chronic conditions not earlier described.
Mental health conditions previously diagnosed or suspected should be included.
· Substance Use/Abuse – Review of past/present use of substances, including type,
method, and frequency of use. Substance use conditions previously diagnosed or
suspected should be included.
· Previous Services – Review of previous treatment received for mental health and/or
substance abuse concerns, including providers, therapeutic modality (e.g., medications,
therapy, rehabilitation, hospitalizations, crisis services, substance abuse groups, detox
programs, Medication for Addiction Treatment[MAT]), length of treatment, and efficacy/
response to interventions.

Medical History and Medications (Domain 4)

Domain 4 integrates medical and medication items into the psychosocial assessment. The
intersection of behavioral health needs, physical health conditions, developmental history, and
medication usage provides important context for understanding the needs of the people we serve.
· Physical Health Conditions – Relevant current or past medical conditions, including the
treatment history of those conditions. Information on help seeking for physical health
treatment should be included. Information on allergies, including those to medications,
should be clearly and prominently noted.
· Medications – Current and past medications, including prescribing clinician, reason for
medication usage, dosage, frequency, adherence, and efficacy/benefits of medications.
When available, the start and end dates or approximate time frames for medication
should be included.
· Developmental History – Prenatal and perinatal events and relevant or significant
developmental history, if known and available (primarily for individuals 21 years old
or younger).

Psychosocial Factors (Domain 5)

Domain 5 supports clinicians in understanding the environment in which the person in care is
functioning. This environment can be on the micro-level (e.g., family) and on the macro-level (e.g.,
systemic racism and broad cultural factors).

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· Family - Family history, current family involvement, significant life events within family
(e.g., loss, divorce, births)
· Social and Life Circumstances – Current living situation, daily activities, social supports/
networks, legal/justice involvement, military history, community engagement, description of
how the person interacts with others and in relationship with the larger social community
· Cultural Considerations – Cultural factors, linguistic factors, Lesbian, Gay, Bisexual,
Transgender, Queer/Questioning and other (LGBTQ+) and/or Black, Indigenous and
People of Color (BIPOC) identities, gender identifications, spirituality and/or religious
beliefs, values, and practices

Strengths, Risk and Protective Factors (Domain 6)

Domain 6 explores areas of risk for the individuals we serve, but also the protective factors and
strengths that are an equally important part of the clinical picture. Clinicians should explore
specific strengths and protective factors and understand how these strengths mitigate risks that
the individual is experiencing.
· Strengths and Protective Factors – personal motivations, desires and drives, hobbies
and interests, positive savoring and coping skills, availability of resources, opportunities
and supports, interpersonal relationships
· Risk Factors and Behaviors – behaviors that put the person in care at risk for danger to
themselves or others, including suicidal ideation/planning/intent, homicidal ideation/
planning/intent, aggression, inability to care for self, recklessness, etc. Include triggers
or situations that may result in risk behaviors. Include history of previous attempts,
family history of or involvement in risks, context for risk behaviors (e.g., loneliness, gang
affiliations, psychosis, drug use/abuse), willingness to seek/obtain help. May include
specific risk screening/assessment tools (e.g., Columbia Suicide Severity Rating Scale)
and the results of such tools used
· Safety Planning – specific safety plans to be used should risk behaviors arise, including
actions to take and trusted individuals to call during crisis.

Clinical Summary, Treatment Recommendations, Level of Care Determination (Domain 7)

Domain 7 provides clinicians an opportunity to clearly articulate a working theory about how
the person in care’s presenting challenges are informed by the other areas explored in the
assessment and how treatment should proceed based on this hypothesis.
· Clinical Impression – summary of clinical symptoms supporting diagnosis, functional
impairments (clearly connected to symptoms/presenting problem), history, mental
status exam, cultural factors, strengths/protective factors, risks, and any hypothesis
regarding predisposing, precipitating and/or perpetuating factors to inform the problem
list (to be explained further below)
· Diagnostic Impression – clinical impression, including any current medical diagnoses
and/or diagnostic uncertainty (rule-outs, provisional or unspecified)
· Treatment Recommendations – recommendations for detailed and specific
interventions and service types based on clinical impression and, overall goals for care.16 17

16 BHIN 21-071 (ca.gov)

17 BHIN21-073 (ca.gov)

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 CLINICAL DOCUMENTATION MANUAL

Diagnosis
Information for the determination of a diagnosis is obtained through a clinical assessment and
may include a series of structured tools. Information may come directly from the person in care
or through other means, such as collateral information or health records. A diagnosis captures
clinical information about the person’s mental health needs and other conditions based on
the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders,
fifth edition (DSM-5). Diagnoses are determined by an LPHA commensurate with their scope of
practice (see Appendix III for scope of practice grid). Diagnoses are used to communicate with
other team members about the person’s mental health symptoms and other conditions and
may inform level of distress/impairment. Moreover, and most importantly, diagnoses may help
practitioners advise the person in care about treatment options.
Diagnoses should not remain static. For example, the person’s clinical presentation may
change over time and/or the practitioner may receive additional information about the
person’s symptoms and how the person experiences their symptoms(s) and conditions. As a
practitioner, it is your responsibility to document all diagnoses, including preliminary diagnostic
impressions and differential diagnoses, as well as to update the person in care’s health record
whenever a diagnostic change occurs.
While there is no longer a limited set of diagnosis codes that are allowable in relation to the
provision of SMHS, the responsibilities of the MHPs related to the MCPs remain unchanged. For
example, MHPs are not required to provide Applied Behavior Analysis (ABA), a key intervention
in the treatment of Autism Spectrum Disorder (ASD), as that responsibility still lies with the MCP.
However, a client who has ASD is able to additionally receive treatment from the MHP if their
service needs require it and are not duplicative.
Providers may use the following options during the assessment phase of a beneficiary’s
treatment when a diagnosis has yet to be established18:
• ICD-10 codes Z55-Z65, “Persons with potential health hazards related to socioeconomic
and psychosocial circumstances” may be used by all providers as appropriate
during the assessment period prior to diagnosis and do not require certification as, or
supervision of, a Licensed Practitioner of the Healing Arts (LPHA) or Licensed Mental
Health Professional (LMHP).
• ICD-10 code Z03.89, “Encounter for observation for other suspected diseases and
conditions ruled out,” may be used by an LPHA or LMHP during the assessment phase of
a beneficiary’s treatment when a diagnosis has yet to be established.
• In cases where services are provided due to a suspected disorder that has not yet been
diagnosed, options are available for an LPHA or LMPH in the CMS approved ICD-10 diagnosis
code list 1, which may include Z codes. LPHA and LMHP may use any clinically appropriate
ICD-10 code19. For example, these include codes for “Other specified” and “Unspecified”
disorders,” or “Factors influencing health status and contact with health services.”

18 https://www.dhcs.ca.gov/Documents/BHIN-22-013-Code-Selection-During-Assessment-Period-for-Outpatient-Behav-
ioral-Health.pdf
19 https://www.dhcs.ca.gov/Documents/BHIN-22-013-Code-Selection-During-Assessment-Period-for-Outpatient-Behav-
ioral-Health.pdf and https://www.cms.gov/medicare/icd-10/2022-icd-10-cm

15
 CLINICAL DOCUMENTATION MANUAL

Care Care
Screening Assessment Problem List Treatment Discharge
Coordination Transitions

The Problem List

In the previous section we explored the assessment and how it informs care recommendations.
Next, we will explore how the diagnosis/diagnoses and the problem list intersect. Below you
can see how different members of the care team can add to the list to fully capture the issues
needing attention.
The use of a Problem List has largely replaced the use of treatment plans20, except where
federal requirements mandate a treatment plan be maintained. The problem list is a list
of symptoms, conditions, diagnoses, and/or risk factors identified through assessment,
psychiatric diagnostic evaluation, crisis encounters, or other types of service encounters. A
problem identified during a service encounter may be addressed by the service provider
during that service encounter, and subsequently added to the problem list. The providers
responsible for the beneficiary’s care create and maintain the problem list. The problem list

includes clinician-identified diagnoses, identified concerns of the person in care, and issues
identified by other service providers, including those by non-LPHA staff. The problem list helps
facilitate continuity of care by providing a comprehensive and accessible list of problems
to quickly identify the person’s care needs, including current diagnoses and key health and
social issues.
When used as intended, treatment teams can use the problem list to quickly gain necessary
information about a person’s concerns, how long the issue has been present, the name
of the practitioner who recorded the concern, and track the issue over time, including its
resolution. The problem list is a key tool for treatment teams and should be kept up to date to
accurately communicate a person’s needs and to support care coordination.
Problem lists will have DSM diagnosis codes, including Z codes, as well as the DHCS Priority SOH
codes21. See Appendix V for a list of DHCS SDOH Priority Codes.

20 Treatment or Care Plans remain in place for some specialty programs, per BHIN 22-019, Attachment 1 https://www.
dhcs.ca.gov/Documents/BHIN-22-019-Documentation-Requirements-for-all-SMHS-DMC-and-DMC-ODS-Services.pdf
21 https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2021/APL21-009.pdf

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Problem List Requirements

The problem list shall be updated on an ongoing basis to reflect the current presentation
of the person in care.
The problem list shall include, but is not limited to, the following:
· Diagnoses identified by a provider acting within their scope of practice, if any.
o Include diagnostic specifiers from the DSM if applicable.
· Problems identified by a provider acting within their scope of practice, if any.
· Problems or illnesses identified by the beneficiary and/or significant support person, if any.
· The name and title of the provider that identified, added, or removed the problem, and
the date the problem was identified, added, or removed.
Providers shall add to or remove problems from the problem list when there is a relevant change
to a beneficiary’s condition.
DHCS does not require the problem list to be updated within a specific time frame or have a
requirement about how frequently the problem list should be updated after a problem has
initially been added. However, providers shall update the problem list within a reasonable time
and in accordance with generally accepted standards of practice.
Accuracy of the diagnoses and problem list are necessary for appropriate treatment services
to a person, and to support claiming for services. Inconsistencies in either can lead to poor
coordination of care across teams and treatment as well as inadequate documentation of the
medical necessity of services, which can lead to rejected claims.

Treatment Plan Requirements

In the past, treatment plans were static and complicated documents with strict start and end
dates. If services were provided that were not documented on the treatment plan, they could
not be claimed. Persons in care had to sign the treatment plans or they were not considered
valid. Over time it has become clear that effective treatment planning involves a more dynamic
process since the client needs are dynamic and can change rapidly. As part of CalAIM,
treatment plans for many types of services are moving from standalone documents to be
embedded in progress notes. Exceptions to these changes can be found in Attachment 1 of
BHIN 22-01922.

A. Targeted Case Management (TCM)

Targeted case management services within SMHS require the development (and periodic
revision) of a specific care plan that is based on the information collected through the
assessment. The TCM care plan:
• Specifies the goals, treatment, service activities, and assistance to address the
negotiated objectives of the plan and the medical, social, educational and other
services needed by the beneficiary;
• Includes activities such as ensuring the active participation of the beneficiary, and
working with the beneficiary (or the beneficiary’s authorized health care decision maker)
and others to develop those goals;
• Identifies a course of action to respond to the assessed needs of the beneficiary; and
• Includes development of a transition plan when a beneficiary has achieved the goals of

22 https://www.dhcs.ca.gov/Documents/BHIN-22-019-Documentation-Requirements-for-all-SMHS-DMC-and-DMC-ODS-
Services.pdf

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the care plan.

These required elements shall be provided in a narrative format in the beneficiary’s
progress notes.

B. Peer Support Services

Peer support services must be based on an approved plan of care.23The plan of care shall be
documented within the progress notes in the beneficiary’s clinical record and approved by any
treating provider who can render reimbursable Medi-Cal services.

C. Additional Treatment and Care Plan Requirements

Requirements for treatment and care planning for additional service types are found in
Attachment 1 of BHIN 22-019 24.

23 https://downloads.cms.gov/cmsgov/archived-downloads/smdl/downloads/smd081507a.pdf; https://www.dhcs.ca.gov/
formsandpubs/laws/Documents/Att-3-1-A-Supp-3.pdf
24 https://www.dhcs.ca.gov/Documents/BHIN-22-019-Documentation-Requirements-for-all-SMHS-DMC-and-DMC-ODS-
Services.pdf

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 CLINICAL DOCUMENTATION MANUAL

Example of a Person in Care’s Problem List:

Number Code Description Begin Date End Date Identified by Provider Type
1 Z65.9 Problem 07/01/2022 07/19/2022 Name Mental Health
related to Rehabilitation
unspecified Specialist
psychosocial
circumstances
2 Z59.02 Unsheltered 07/01/2022 Current Name Peer Support
homelessness Specialist

3 Z59.41 Food insecurity 07/01/2022 Current Name Peer Support

Specialist

4 Z59.7 Insufficient 07/01/2022 Current Name Peer Support

social Specialist
insurance and
welfare support
5 F33.3 Major 07/19/2022 Current Name Psychiatrist
Depressive
Disorder
recurrent,
severe with
psychotic
features
6 F10.99 Alcohol Use 07/19/2022 Current Name Clinical Social
Disorder, Worker
unspecified
7 I10. Hypertension 07/25/2022 Current Name Primary Care
Physician
8 Z62.819 Personal 08/16/2022 Current Name Clinical Social
history of Worker
unspecified
abuse in
childhood

Care Care
Screening Assessment Problem List Treatment Discharge
Coordination Transitions

Care Coordination
In the previous sections, we explored social determinants of health and their contribution to
quality of life based on access to resources. Access to health care requires services to be
available and accessible at the time the person needs the services. It also requires practitioners
to work alongside the person in care throughout their health care journey and to take a stance
of curiosity and ask meaningful questions aimed at understanding the person within the
context of their culture, community, and help seeking behaviors. By doing so, we are in better

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alignment with developing care and treatment recommendations that support a person-
centered approach. However, as practitioners, we must further support the access to other
necessary resources through coordination efforts across systems and providers, while keeping
the person in care as the central and most important voice on the team.
Care coordination is necessary, requiring the practitioner to be intentional and informed about
coordinating activities or services with other providers to best meet the person in care’s needs.
We know far too well that accessing and navigating healthcare systems can be a challenge for
anyone. This may be especially true in behavioral health because care coordination involves
treatment providers across multiple disciplines and organizations. A person may receive care
by multiple providers within the MHP or other external entities, all at the same time. To ensure
smooth coordination of care, practitioners should request authorization to share information
(also known as releases of information) for all others involved in the care of the person in
treatment during the intake process and throughout the course of treatment.
Care coordination benefits from a point person who is accountable for coordination, bringing
the person in care, natural supports/family, all service providers and system partners to the
table. The Care Coordinator may be you, a treatment team member from your organization, or
a treatment provider from another organization or delivery system. This role may have different
names within various organizations, such as case manager, care manager, team facilitator,
or the function of care coordination may be incorporated into the role of a clinician or other
staff. The main goal of the Care Coordinator is to meet the person’s care needs by using care
information in a deliberate way and sharing necessary information with providers and the
person in care, to guide the delivery of appropriate and effective care. Care coordinators work
to build teams and facilitate partnerships, creating formal and informal networks of support
that enhance treatment for persons in care and allow for sustainable support long after
treatment ends. Care coordination serves as a key element of service planning, ensuring that
treatment across the team is meeting the needs of the person in care, that plans are updated
as needed and that barriers to success are overcome. Within the team, communication is a
key element of success, along with empowering the person in care to guide the team to meet
their own needs. When referring or transitioning a person in care, the practitioner should discuss
the reason for referral or transition and ensure the person understands, not only the reason for
referral or transition, but also the expected outcome of the referral or transition. In January 2023,
DHCS will launch a universal tool for transitioning between MHPs and MCPs to assist with care
coordination and communication during transitions.

Care Care
Screening Assessment Problem List Treatment Discharge
Coordination Transitions

Treatment
Stages of Change
While the assessment, diagnosis, and problem list are necessary to understanding the person’s
overall care needs, equally as important is the consideration of the stage in which the person is
in their stage of recovery. The Stages of Change25 framework supports practitioners in meeting

25 Prochaska, J.O, & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psycho-
therapy: Theory, Research and Practice, 19, 276-287.

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the person where they are. Their readiness for change offers empowerment to the person. This
framework lends itself to the identification of evidence-based interventions compatible with
each stage of change and supports the conceptualization of change as a continuum. Change
is not considered a linear process and should be evaluated throughout the course of care.
Moreover, a person may be in different stages of change relative to each issue. Movement
from stage to stage may vary per person and may, at times, move backwards in addition to
forwards through the stages. Some persons may move faster than others, while others may
plateau in one stage for a longer period. A practitioner may take this opportunity to engage the
person in understanding the situation.
We should note, relapse or reversion in symptoms, behaviors and/or functioning is a normal
part of the change process. When relapse occurs, practitioners should take time to evaluate the
situation alongside the person in care and continue to encourage and explore pros and cons of
changes. Next, let us explore the framework.

Stage Description Potential Behaviors

Precontemplation This is the period prior to any Seeking services due to

action towards change. The pressure of others (i.e.,
person has not yet begun to think parent, partner, employer,
about change. Person is not aware courts). Place responsibility of
they have a problem. problems on other factors or
persons.

Contemplation Person is aware they have a Considerations of the pros

problem. During this period, the and cons of change are
person begins to consider the weighed. Action may take
possibility of change and begins place if pros outweigh cons.
to evaluate the benefits of making Planning may take place the
change. Not fully dedicated to next few months.
taking action.

Preparation Person begins planning to make Person is future thinking and

changes to what they are most focused on their commitment.
committed to. Adjustments begin
toward making change.

Action Specific changes to aspects of Person is actively modifying

life that are contributing to their behaviors and is
undesired situation or problem. committed to change.
Changes may be behavioral or
environmental. Changes may
include decreasing unhealthy
behaviors or increasing health ones.

Maintenance Actively working to sustain Person is committed to

previously changed behaviors. maintaining changes. Requires
strong commitment of the
person to avoid reverting to
previous behaviors. Person
has strong supports, including
community connectedness.

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 CLINICAL DOCUMENTATION MANUAL

Motivational Interviewing
Built on the Stages of Change model, service providers tend to find that principles of
Motivational Interviewing (MI)26 align closely with the person in care’s treatment needs, is
applicable in a broad range of settings and works well in combination with other common
clinical practices. MI is an approach that addresses the comprehensive needs of people in care,
views the person in care as an equal partner in the therapeutic process and integrates a focus
on moving through the stages of change to support building motivation. People in care develop
insight and skills through the use of focused MI interventions when service providers meet the
individual where they are in their thinking about change and believe that people are the experts
in their own lives. 
Service providers use MI styles of communication to demonstrate respect and curiosity in ways
that empower people in care to move through the recovery process. People in care experience
incremental success and, through each step towards goal attainment, develop confidence
in their ability to recover from their mental health and/or substance use challenges. In the
MI model, the person in care, rather than the service provider, should present the arguments
for change. This happens through a variety of strategic responses focused on enhancing the
individual’s understanding of change and building intention towards change. Individuals are
invited to new perspectives, but these perspectives are not imposed on the person in care.
Service providers support individuals in moving through the Stages of Change through four
widely applicable processes:

1. Engaging

a. Accepting people as they are in order to free them to change

b. Employing acceptance and respect, normalize ambivalence and affirm strengths

2. Focusing

a. Development of shared purpose

b. Assessing how important the person in care thinks change is in their life – life goal
analysis, values exploration, discrepancy development.

3. Evoking

a. Building the case for change – developing a “why”

b. Exploration of ambivalence and change talk

4. Planning

a. Development of plans for change – exploration of the “how”

b. Supporting self-efficacy and exploring previous successes the person in care has
experience to increase their confidence in their ability to change.

MI is especially useful when a person in care is in the pre-contemplation and contemplation

stages of change. As is true with other EBPs, it is vital that a person is not only well-trained in
MI, but also continues to receive supervision, consultation, or mentorship to ensure that it is
performed with fidelity to the model.

26 https://motivationalinterviewing.org/understanding-motivational-interviewing

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 CLINICAL DOCUMENTATION MANUAL

Treatment Services
Medi-Cal SMHS are comprised of a variety of treatment services provided to individuals, groups
and/or families. A list and definition of the primary service types are below.
Assessment: Service activity which may include a clinical analysis of the history and current
status of a person in care’s mental, emotional, or behavioral disorder; relevant cultural issues
and history; diagnosis; and the use of testing procedures.
Plan Development: Service activity which consists of development of plans, approval of plans,
and/or monitoring of a person in care’s progress.
Targeted Case Management (Case Management/ Brokerage/Linkage): Services that assist
a person in care to access needed medical, educational, social, prevocational, vocational,
rehabilitative, or other community services. The service activities may include, but are not
limited to, communication, coordination, and referral; monitoring service delivery to ensure
access to service and the service delivery system; monitoring of individual progress.
Intensive Care Coordination (ICC): Service that is responsible for facilitating assessment, care
planning, and coordination of services, including urgent services, to foster and/or probation
involved youth. Includes work within the Child & Family Team (CFT) to ensure that plans from
any of the system partners (mental health, child welfare, education services, probation, etc.)
are integrated to comprehensively address goals and objectives. Also includes facilitation and
participation in CFTs and team coordination to ensure participation by the child or youth, family
or caregiver and other natural or paid supports so that the assessment and plan addresses
the child or youth’s needs and strengths in the context of the values and philosophy of the
Pathways to Mental Health Core Practice Model27.
Collateral: Service activity to a significant support person in an individual’s life with the intent
of improving or maintaining the mental health status of the person in care. The person in care
may or may not be present for this service activity. Service activity to a significant support
person or persons in a beneficiary’s life for the purpose of providing support to the beneficiary in
achieving client plan goals. Collateral includes one or more of the following: consultation and/
or training of the significant support person(s) that would assist the beneficiary in increasing
resiliency, recovery, or improving utilization of services; consultation and training of the
significant support person(s) to assist in better understanding of mental illness and its impact
on the beneficiary; and family counseling with the significant support person(s) to improve
the functioning of the beneficiary. The beneficiary may or may not be present for this service
activity.
Rehabilitation: Service activity which includes assistance in improving, maintaining, or restoring
an individual or group of individuals functional skills, daily living skills, social and leisure skills,
grooming and personal hygiene skills, meal preparation skills, and support resources; and/or
medication education. May be provided individually or in a group setting.
Intensive Home-Based Services (IHBS): Services are individualized, strength-based
interventions designed to address behaviors and/or symptoms that interfere with a youth’s
functioning. Interventions are aimed at helping the youth build skills necessary for successful
functioning in the home and community and improving the family’s ability to help the youth
successfully function in the home and community. Must be determined necessary by the CFT
and documented in the CFT action plan.
Therapy: Service activity which is a therapeutic intervention that focuses primarily on

27 https://calswec.berkeley.edu/programs-and-services/child-welfare-service-training-program/core-practice-model

23
 CLINICAL DOCUMENTATION MANUAL

symptom reduction as a means to improve functional impairments. Therapy may be

delivered to an individual or group of beneficiaries and may include family therapy at which
the person in care is present. Therapy may only be provided by LPHA staff or Psychiatrists/
Psychiatric Nurse Practitioners.
Medication Support Services: Services provided by medical staff which include prescribing,
administering, dispensing and monitoring of psychiatric medications or biologicals which are
necessary to alleviate the symptoms of mental illness. The services may include evaluation of
the need for medication, evaluation of clinical effectiveness and side effects, the obtaining of
informed consent, medication education and plan development related to the delivery of the
service and/or assessment of the youth.
Crisis Intervention: Service, lasting less than 24 hours, to or on behalf of a youth for a condition
which requires more timely response than a regularly scheduled visit. Service activities may
include but are not limited to assessment, collateral, and therapy. Note that billing for crisis
intervention services is limited to 8 hours per instance.

Treatment Team
SMHS services are often provided through a team-based approach. While the precise
composition of teams varies in each individual situation, it is not uncommon to have treatment
teams with some combination of LPHAs, Mental Health Rehabilitation Specialists (MHRS), Peer
Support Specialists, medical providers and others who work with the person in care. It is critical
that treatment teams include the person in care and center their voice and priorities as the
treatment team collaborates to support the person in care in meeting their goals. Teaming
should be a seamless part of treatment and all members should work collaboratively to ensure
that work is highly coordinated and aligned across providers. Doing this well takes intentional
partnership, information-sharing, and focus. Treatment teams are highly encouraged to use
consensus building decision making techniques and to solicit and explore viewpoints across
the team.

Co-Occurring Treatment
A substantial number of people experience co-occurring mental health and substance
use disorders. These conditions can be treated via “co-occurring treatment”, with clinically
appropriate services for mental health conditions in the presence of a co-occurring substance
use disorder, covered in all delivery systems. Likewise, clinically appropriate services for
substance disorders in the presence of a co-occurring mental health disorder are also covered
in all delivery systems.
This means that a person in care may receive clinically appropriate, covered services by the
delivery system they sought care under that may be coordinated and co-treated. A person’s
behavioral health condition may be addressed for problems identified on a person’s problem
list. All services shall be delivered within the practitioner’s scope of competence.

Progress Notes
In previous sections, we explored the use of the screening tools, assessment, diagnosis, and
problem lists to best identify the person’s care needs and treatment options. Now, we will explore
the use of progress notes for documenting services as practitioners work with individuals to
address their needs.
Progress notes have multiple functions. First and foremost, progress notes are used as a

24
 CLINICAL DOCUMENTATION MANUAL

basis for planning care and treatment among practitioners and across programs. Progress
notes are communication tools; therefore, each progress note should be understandable
when read independent of other progress notes. This means, documentation should provide
an accurate picture of the person’s condition, treatment provided, and response to care at the
time the service was provided.
Secondly, progress notes are considered a legal record describing treatment provided for
reimbursement purposes. The progress note is used for verification of billed services for
reimbursement. As such, there must be sufficient documentation of the intervention, what was
provided to or with the person, to justify payment. See Appendix VI for sample note narratives
that provide sufficient documentation of the intervention.
Lastly, as noted earlier, progress notes are also used to communicate with other care providers.
For these reasons, abbreviations should be avoided, unless universally recognized, to facilitate
clear and accurate communication across providers and for when notes are used for legal or
other reasons. Keep in mind that the person in care has legal privilege to their medical record
and may review the medical record documentation. They should be able to recognize the
treatment described; therefore, it is recommended that clinical or programmatic jargon be
avoided.

The following list are characteristics of a progress note that supports quality documentation.
Consider the following characteristics when documenting28:
 Clear  Reliable
 Consistent  Accurate/Precise
 Descriptive  Timely

Required Progress Note Service Information

 They type of service rendered
 A narrative describing the service, including how the service addressed the beneficiary’s
behavioral health need (e.g., symptom, condition, diagnosis and/or risk factors).
 The date that the service was provided to the beneficiary.
 Duration of the service, including travel and documentation time.
 Location of the beneficiary at the time of receiving the service.
 A typed or legibly printed name, signature of the service provider and date of signature.
 ICD 10 code.29
 Current procedural terminology (CPT) or Healthcare Common Procedure Coding System
(HCPCS) code.
 Next steps including, but not limited to, planned action steps by the provider or by the
beneficiary, collaboration with the beneficiary, collaboration with other provider(s) and
any update to the problem list as appropriate.
Group Progress Notes
The information above remains consistent for services provided in a group setting, with the
following additional requirements:
· For groups facilitated by multiple practitioners, a single progress note signed by one

28 Hess, Pamela Carroll. Clinical Documentation Improvement: Principles and Practice. Chicago: AHIMA Press, 2017.
29 https://www.cms.gov/medicare/icd-10/2022-icd-10-cm

25
 CLINICAL DOCUMENTATION MANUAL

of the practitioners shall be used to document the group service provided. Progress
notes shall contain the information as noted above and modifications and additional
information as noted below:
· Information about the specific involvement and specific amount of time of involvement of
each practitioner in the group activity, including time spent traveling to/from the service
and documenting the service.
· A list of group participant names shall be maintained. Please note, due to confidentiality
standards, the full list of group participants must not be kept in any single participant’s
personal health records, instead the MHP or practitioner must maintain the full participant
list outside of any participant’s health records.

Progress Notes Timeliness

As noted above, each progress note should stand alone and be clear, complete, accurate, and
free of jargon and local abbreviations. Documentation should be completed in a timely manner
to support the practitioner’s recall of the specifics of a service. Progress notes should never be
completed in advance of a service. Below are timeliness expectations determined by DHCS:
· Routine outpatient services: Documentation should be completed within three business
days. If a note is submitted outside of the three business days, it is good practice to
document the reason the note is delayed. Late notes should not be withheld from the
claiming process. Based on the program/facility type (e.g., STRTP DHCS regulations30),
stricter note completion timelines may be required by state regulation.
· Crisis services: Documentation should be completed within 24 hours.
· A daily note is required for documentation of some residential services, day treatment,
and other similar settings that use a daily rate for billing. In these programs, weekly
summaries are no longer required.
Compliance within a Medi-Cal context is focused on ensuring that there is no fraud, waste,
and abuse31 within the service provision and claiming system. Disallowances in audits will only
occur when there is evidence of fraud, waste, and abuse. Documenting accurately, in a timely
manner and in alignment with the guidelines listed in this manual are necessary steps to
promote compliance.

Care Care
Screening Assessment Problem List Treatment Discharge
Coordination Transitions

Care Transitions
Given the multiple healthcare delivery systems and resources that a person in care can be
served in, there is a need for care coordination to successfully transition between providers
and care settings. We should think about care as occurring across a continuum with an
understanding that people’s needs change over time. Given that individual needs can also
be addressed concurrently by providers in different agencies or systems, coordination of care
is a necessary element of your service provision. The goal of care coordination is to meet the

30 https://www.dhcs.ca.gov/Documents/STRTP-Regulations-version-II.pdf
31 Fraud and abuse are defined in Code of Federal Regulations, Title 42, § 455.2 and W&I Code, section 14107.11, subdivision
(d). Definitions for “fraud,” “waste,” and “abuse” can also be found in the Medicare Managed Care Manual.

26
 CLINICAL DOCUMENTATION MANUAL

person’s needs though proactive and deliberate activities that include the person in care and
to organize or coordinate with other service providers to facilitate the appropriate delivery
of services across providers, treatment settings, and healthcare systems. It is likely that the
coordination of services may include other treatment team members to help carry out
activities, with each provider identifying what roles and activities they are taking on that support
the person in care’s overarching wellness.
As noted earlier in this manual, there are multiple service delivery systems that cover distinct
Medi-Cal services, with some not covered under the MHP or best provided by another
delivery system. Although a person may receive care from more than one delivery system
or provider, the practitioner or Care Coordinator must ensure this is done without duplication.
To avoid duplication of care and to facilitate the transitions between healthcare systems,
DHCS is developing child and adult transition of care tools. Let us explore these tools with an
understanding that additional information will be provided by DHCS regarding the transition of
care tools in the future.

Care Care
Screening Assessment Problem List Treatment Discharge
Coordination Transitions

Discharge Planning
Mental health treatment should always commence with the understanding that recovery is
possible. Appropriate treatment and supports benefit people with a wide variety of conditions;
lessening disability and improving the ability to live full and fulfilling lives. For this reason, the
discussion about discharge planning begins at the time of initial assessment (as clinically
appropriate) and continues throughout the course of treatment. Routinely asking yourself
and the person in care how you will know when they are ready to discontinue treatment and
what they imagine their life will look like after treatment is a valuable discussion that enhances
engagement and instills hope for the future.
Discharge planning must include the person in care and their social supports as full partners in
the planning process and should be done as far in advance as practical. Additionally, including
other treatment providers, when applicable, paves the ways to successful transitions from one
care setting to another. Detailed information on discharge planning should be clear, concise,
and accurately communicated and documented.
A successful discharge discussion includes a review of how the person can continue to
receive any necessary support and how those needs may be addressed post-discharge from
the program. Information contained in discharge plans and shared with the person in care
includes how the person’s needs may be addressed, information on prescribed medications,
the type of care the person is expected to receive and by whom, information on crisis supports,
and available community services, to name a few. Additionally, to document the needs and
strengths of the individual as they are leaving care, providers who work with individuals under
age 21 are also required to complete a CANS and PSC-35 at discharge.

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 CLINICAL DOCUMENTATION MANUAL

Claiming for Services

Code Sets for Claiming Services
In an earlier section we explored the importance of identifying needs, assessing for conditions
and/or diagnoses to recommend medically necessary services and initiate care planning and
treatment. Here, we will explore the intersection of progress notes with code sets for submitting
claims for reimbursement. But first, let us talk about the different code sets and their uses.
· DSM Diagnosis: Captures clinical information about the person’s mental health needs
and other conditions (clusters of symptoms) based on the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).
Treatment intervention is based on diagnosis, assessed need and problem list.
· International Classification of Diseases - Clinical Modification (ICD-10-CM) Codes:
Captures detailed information about the disorder (granular information) and is used in
claiming. The ICD is a standard transaction code set for diagnostic purposes under the
Health Insurance Portability and Accountability Act (HIPAA).
· Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding
System (HCPCS) Codes: These codes are used to capture uniform information for billing
medical services and procedure. County Behavioral Health currently uses primarily HCPCS
codes to bill Medi-Cal. Starting in July 2023, a subset of services will be claimed using CPT
codes. More information to follow.

These code sets are used throughout healthcare settings and offer standardization and
uniformity for data collection, claims processing, and evaluation of disease prevalence and
service provision. Now, let us take a brief look at the interplay of how interventions and code sets
are used to claim for reimbursement of services.

Diagnosis and ICD-10 Codes

While a mental health diagnosis is not a prerequisite for access to covered services and a
person may receive services prior to a final diagnosis, a diagnosis and corresponding ICD-
1032 code must be present on the claim for processing. Annually, the Centers for Medicare and
Medicaid Services (CMS) publishes the approved lists of ICD codes to be used for Medicaid
(Medi-Cal) reimbursement.33 The CMS-approved ICD-10 code set includes options for use when
services were rendered prior to establishing a diagnosis or when access criteria is met by means
other than by diagnosis, such as due to trauma. In these instances, for example, the ICD-10 list
includes codes for “other specified” and “unspecified disorders” or “factors influencing health
status and contact with health services” (i.e., Z Codes). Each of these codes are allowable for
Medi-Cal billing and can be used to claim for services.

Commonly Used Codes

Several elements are required for the successful submission of service claims for processing,
including a diagnosis (preliminary, provisional or otherwise), a corresponding ICD-10 code, and either
a CPT code or a HCPCS code. DHCS has issued guidance on the most commonly utilized codes.34

32 BHIN 22-013 (ca.gov)

33 2022 ICD-10-CM | CMS
34 BHIN 22-013 (ca.gov)

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 CLINICAL DOCUMENTATION MANUAL

Conclusion
We hope that this manual has given you useful tools to implement the service delivery system
transformation and documentation redesign concepts foundational to CalAIM. Achieving
the goals of CalAIM requires transformation across our system, including in the practice
and documentation of services provided by LPHAs. Through coordination of care and strong
engagement with the person in care, LPHAs can streamline documentation and provide higher-
quality care and further the goals of improving access for all Californians.

29
 APPENDICES

Appendices
Appendix I: Acronym List
· ACE: Adverse Childhood Experience
· BHIN: Behavioral Health Information Notice
· BIPOC: Black, Indigenous and People of Color
· CalAIM: California Advancing and Innovating Medi-Cal
· CANS: Child and Adolescent Needs and Strengths
· CMS: Centers for Medicare & Medicaid Services
· CPT: Current Procedural Terminology
· DHCS: Department of Health Care Services
· DMC: Drug Medi-Cal
· DMC-ODS: Drug Medi-Cal Organized Delivery Services
· DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
· EPSDT: Early Periodic Screening, Diagnosis and Treatment
· FFS: Fee-for-Service
· HCPCS: Healthcare Common Procedure Code System
· HIPAA: Health Insurance Portability and Accountability Act
· ICD-10: International Classification of Diseases, Tenth Revision
· LGBTQ+: Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, and others
· LOC: Level of Care
· LPHA: Licensed Practitioner of the Healing Arts
· MAT: Medication for Addiction Treatment
· MCO: Managed Care Organization
· MCP: Managed Care Plan
· MHP: Mental Health Plan
· PSC-35: Pediatric Symptoms Checklist
· SMHS: Specialty Mental Health Services
· SUD: Substance Use Disorder
· TCM: Targeted Case Management

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 APPENDICES

Appendix II: Medi-Cal Plans by Type

Medi-Cal Benefits

System Operated by Services Service Definition

Mental Health County Specialty SMHS includes the following36:

Plan (MHP) Behavioral Mental Health · Inpatient psychiatric services
Health Services
Departments (SMHS) – · Outpatient services, including intensive
Carved out of and community-based services, such
overall Medi- as individual, family and group therapy,
Cal benefit collateral, plan development and
within 1915b assessment.
Waiver35 · Rehabilitative skill building services in
individual and/or group settings
· Targeted Case Management
· Medication Support Services
· Day Treatment Intensive or
Rehabilitation
· Crisis Intervention and Stabilization
· Adult and Crisis Residential Treatment
· Psychiatric health facilities
· Population specific services such
as Intensive Care Coordination,
Therapeutic Foster Care, Intensive
Home-Based Services and Therapeutic
Behavioral Services

Managed Private Non-Specialty NSMHS include the following:

Care Plan insurance Mental Health • Mental health evaluation and treatment,
(MCP) companies Services including individual, group and family
contracted (NSMHS) psychotherapy
with and Physical
Department Healthcare • Psychological and neuropsychological
of Health Care testing, when clinically indicated to
Services37 evaluate a mental health condition
• Outpatient services for purposes of
monitoring drug therapy
• Psychiatric consultation
• Outpatient laboratory, drugs, supplies
and supplements

35 https://www.dhcs.ca.gov/provgovpart/Pages/CalAIM-1115-and-1915b-Waiver-Renewals.aspx
36 https://www.dhcs.ca.gov/services/MH/Documents/PPQA%20Pages/Boilerplate_2017-2022_MHP_Contract-Exhibits_A_B_
and_E.pdf
37 Managed Care Plans by county

31
 APPENDICES

Fee For Department Non-Specialty Same as available through MCP, however

Service (FFS) of Health Care Mental Health typically through private practitioners or
Providers Services Services clinics.
(NSMHS)
and Physical
Healthcare

County Drug County ASAM Level Continuum of Care modeled after the
Medi-Cal Behavioral of Care American Society of Addiction Medicine
Organized Health Substance (ASAM) criteria38 including:
Delivery Departments Use · Outpatient
System Treatment
(DMC-ODS) · Intensive Outpatient
· Partial Hospitalization
· Residential Treatment (low and high
intensity)
· Inpatient (Medically Monitored or
Medically Managed)
· Opioid Treatment Program OTP) and
other Medication for Addiction
Treatment (MAT)

Drug Medi- State Substance Includes the following39:

Cal (DMC) Department Use · Narcotic Treatment Programs
of Health Treatment
Care Services · Outpatient drug free treatment,
(DHCS) including medication services,
treatment planning, crisis intervention,
collateral, individual counseling, and
group counseling.
· Day Habilitative services
· Perinatal residential
· Naltrexone treatment

38 ASAM LOC Criteria

39 https://govt.westlaw.com/calregs/Document/I12C91B008DA411E4A0F094BBA3CAFB62?transitionType=Default&context-
Data=%28sc.Default%29

32
 APPENDICES

Appendix III: Sample Progress Note Treatment Plan Template

Client’s goal(s) in their own words:

To meet these goal(s), client participated actively in the development of this plan and will
receive case management/peer support services to address the below concerns:

Activities of Daily Living  Food Insecurity 

Access to IDD Services  Housing Instability 

Accessing Medical/Dental Care  Legal Concerns 

Access to Non SHMS  Parenting Support 

Educational Concerns  Recreation/Leisure 

Employment/Vocational Support  Access to Substance Use Treatments 

Family/Social Support  Transportation Issues 

Financial Concerns  Other (Describe) 

33
 APPENDICES

Appendix IV: Scope of Practice Matrix

Physician Licensed or Licensed, RN with Psychiatric Registered Licensed Trainee/ Mental Health Certified Peer Other Qualified
Waivered Registered or Master’s degree Nurse Nurse Vocation Nurse/ Student/Intern: Rehabilitation Specialist Staff approved
Psychologist Waivered staff: in MH Nursing or Practitioner Licensed Post BA/BS Specialist: BA/ by BH Director:
(post ACSW/LCSW, related field Psychiatric degree. Enrolled BS in MH related typically 18+,
doctorate) AMFT/LMFT, Technician in MA/MS/ field and 4 yrs High School
APCC/LPCC doctorate MH experience Equivalency,
(post MA/MS) program Driver’s License

Assessment: MH + medical history, SU Yes Yes Yes Yes Yes Yes Yes* Yes* Yes* Yes* Yes*
+ exposure, strengths, risks, barriers to
achieving goals
Assessment: : Dx, MSE, medication Yes Yes Yes Yes Yes No No Yes* No No No
hx,assessment of relevant conditions
and psychosocial factors affecting the
individual’s physical and MH
Behavioral Health Prevention No No No No No No No No No Yes* No
Education Service
Collateral Yes Yes Yes Yes Yes Yes Yes* Yes* Yes* Yes* Yes*
Care/Client/Treatment Plan Yes Yes Yes Yes Yes Yes Yes* Yes* Yes* Yes* Yes*
Crisis Intervention Yes Yes Yes Yes Yes Yes++ Yes++ Yes*,++ Yes++ Yes++ Yes*,++
Intensive Care Coordination (ICC) No Yes Yes No No No No Yes* Yes* Yes* Yes*
Intensive Home-Based Services (IHBS) No Yes Yes No No No No Yes* Yes* Yes* Yes*

Medication Support Yes No No Yes Yes Yes Yes No No No No

Medication Prescribing or Furnishing Yes No No No Yes No No No No No No
Medication Administration Yes No No Yes Yes Yes Yes No No No No
Medication Dispensing Yes No No Yes+ Yes Yes+ No No No No No
Plan Development Yes Yes Yes Yes Yes Yes Yes* Yes* Yes* Yes* Yes*
Problem List Yes Yes Yes Yes Yes Yes Yes* Yes* Yes* Yes* Yes*
Psychological Testing No Yes No No No No No Yes+++ No No No
Psychotherapy Yes Yes Yes Yes Yes No No Yes* No No No
Rehabilitation Counseling No Yes Yes Yes No Yes Yes* Yes* Yes* Yes* Yes*
Self Help/Peer Services No No No No No No No No No Yes* No
Targeted Case Management Yes Yes Yes Yes Yes Yes Yes* Yes* Yes Yes* Yes*
Therapeutic Behavioral Services No Yes Yes No No No No Yes* Yes* Yes* Yes*

*Under the direct supervision of an LPHA/LMHP

+ Training and certification requirement may apply
++ May require close supervision if issues of danger to self or others are present
+++ Typically limited to post-master’s doctorate students

34
 APPENDICES

Appendix V: DHCS Priority SDOH Codes

Code Description

Z55.0 Illiteracy and low-level literacy

Z58.6 Inadequate drinking-water supply
Z59.00 Homelessness unspecified
Z59.01 Sheltered homelessness
Z59.02 Unsheltered homelessness
Z59.1 Inadequate housing (lack of heating/space, unsatisfactory surroundings)
Z59.3 Problems related to living in residential institution
Z59.41 Food insecurity
Z59.48 Other specified lack of adequate food
Z59.7 Insufficient social insurance and welfare support
Z59.811 Housing instability, housed, with risk of homelessness
Z59.812 Housing instability, housed, homelessness in past 12 months
Z59.819 Housing instability, housed unspecified
Z59.89 Other problems related to housing and economic circumstances
Z60.2 Problems related to living alone
Z60.4 Social exclusion and rejection (physical appearance, illness or behavior)
Z62.819 Personal history of unspecified abuse in childhood
Z63.0 Problems in relationship with spouse or partner
Z63.4 Disappearance & death of family member (assumed death, bereavement)
Z63.5 Disruption of family by separation and divorce (marital estrangement)
Z63.6 Dependent relative needing care at home
Z63.72 Alcoholism and drug addiction in family
Z65.1 Imprisonment and other incarceration
Z65.2 Problems related to release from prison
Other specified problems related to psychosocial circumstances (religious or
Z65.8
spiritual problem)

35
 APPENDICES

Appendix VI: Sample Progress Note Narratives

Assessment

This clinician conducted an initial intake assessment with client. This clinician
gathered information about the reason for seeking treatment, from the client’s
perspective. This clinician asked direct questions to assess for current risk and safety
concerns. Clinician evaluated current symptoms of anxiety, irritability, pervasive
worrying, and racing thoughts that are significantly impacting client’s ability to
function at home and work. This evaluation led to a determination that symptoms
and impairments are consistent with a provisional diagnosis of Generalized Anxiety
Disorder. Discussed challenges client experiences in meeting financial needs and
maintaining stable housing. Clinician then worked with client to reach a consensus
on the needs to prioritize in treatment. Client was verbal and engaged throughout
the session. Clinician will complete assessment documentation and problem list for
review at next session. Next session planned in one week.

Assessment

This clinician reviewed collateral information, as well as information provided

by client, and her father, in order to complete the comprehensive assessment.
This documentation included information on client placement history, strengths,
diagnostic information, presenting issues, trauma history, risk behaviors, family and
support information, goals, and the beginning of discharge planning.
Client presents with symptoms of depression (hopelessness, sadness, and low self-
worth), suicidal and self-injurious behavior, aggression toward others, and running
away. Client reports her last substance use occurred in one month ago. She denies
current suicidal ideation and states that her last ideation was 8 months ago, as was
her last attempt at self-injury (cutting).
Client and her father identified individual strengths as a good sense of humor,
optimistic, social, caring and being a good friend. Client reports being very close to
her family, and they identified family strengths as humor, supportive of one another,
and loving.
Preliminary diagnosis of Major Depressive Disorder, Recurrent, Severe with Psychotic
Features established. Assessment completed.
This clinician plans to meet with the client and her family, as well as the Child and
Family Team to review the problem list.

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Plan Development/Problem List

I collaborated with client to develop his initial problem list. I prompted client to share
his life goal and brainstormed how it would be incorporated into his problem list. I
reviewed the needs and strengths identified during the assessment and worked with
client to determine how to leverage his strengths to support his areas of need. Client
was engaged throughout the session, though he struggled to identify strengths.
Client was in agreement with the problem list developed. This clinician will begin
individual and family therapy sessions later this week.

Individual Therapy

Client continues to violate the terms of her probation and is engaging in high-risk
behaviors (e.g., illicit substance use, high risk sexual behavior). In order to convey
concern for client, this clinician inquired about her wellbeing and recent behavior.
This clinician provided her with unconditional positive regard and acceptance.
Facilitated discussion with client about her thought processes leading to her
choices to violate her probation and prompted her to consider what her behavior
is communicating to those who are trying to help her. Discussed plan for following
through with avoiding high risk situations. Encouraged client to elicit the help of the
friend identified by her as a primary support and source of encouragement to do
what is in her best interest. Client continues to be very present minded and struggles
to connect thoughts to behavior. She was able to independently recognize that her
behavior is incongruent with her goals for herself. This clinician plans to continue
to meet with client weekly to work toward increasing her ability to manage her
impulsive and high-risk behavior.

Individual Rehabilitation

In effort to monitor client’s moods and emotions, I engaged her in an open-ended

conversation about her day and how she has been feeling. I praised her for her
reported positive day. I validated her responses and responded with empathy,
encouraging her to express her feelings. I discussed and reviewed her current coping
skills (i.e., reading, listening to music, etc.). I normalized her need to take a break from
difficult situations and reminded her to take time outside. Assisted client in practicing
how to let others know that she needs to use her safety plan by engaging in a role
play. Client was verbal and engaged throughout the session. I will meet with client
next week for an individual rehabilitation session to support her with developing and
utilizing coping skills.

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Case Management

This staff provided the following case management intervention to address the
client’s inability to manage emotions due to their anxiety. This staff contacted Group
Intervention Center and spoke with intake counselor (Susan) to obtain information
about the appropriateness of their Healing Heart Program to meet client’s needs.
Staff completed the referral process by summarizing client’s anxiety symptoms
and highlighting strengths, including supportive family members. Healing Hearts
indicated client seemed appropriate for their program group and provided staff
with information on next steps. This staff will contact client to discuss eligibility for
program and assist client in preparing to attend this support group.

Collateral

Client’s father and grandmother report that on most days, client closes herself off
in her bedroom as soon as she comes home on visits and only leaves her room
to meet basic physical needs. These behaviors resulting from client’s depression
are creating challenges in family relationship, per father. This clinician provided
empathic and validating statements, acknowledging caregiver’s frustration
and concern. Clinician provided psychoeducation around the various ways that
anxiety can manifest behaviorally, especially in adolescents. Clinician discussed
common challenges amongst families when there are notable differences in the
expression of respect between the generations within household. Clinician solicited
feedback from caregivers about whether or not the experience of generational
differences resonated with them. Client’s caregivers were forthcoming in expressing
their challenges to understand how to best support client. They were receptive
to information and expressed willingness to try new approaches with client. This
clinician will continue to work with client’s family in identifying new methods to
respond to client’s isolative behavior.

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Appendix VII: Documentation Manual Change Log

Version Section No. Change Description Revision Date

Any questions & comments related to this manual can be submitted to:

info@calmhsa.org

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