3.   Admission or initial assessment must include:

• Current support systems.
• Lack of support systems.

4.   Behavioral health treatment - documented assessment at each visit for client status and symptoms, indicating:

• Decreased
• Increased
• Unchanged
• A plan of treatment, including:
• Activities.
• Therapies.
• Goals to be carried out.
• Diagnostic tests.
• Evidence of family involvement in therapy sessions and/or treatment.

5.   Follow-up care encounter forms or notes indicating follow-up care, call or visit in weeks, months or PRN.

6.   Referrals and results of all other aspects of patient care and ancillary services.

We systematically review medical records to ensure compliance and institute actions for improvement when our standards are not met.

We maintain a professional recordkeeping system for services to our members. We make all medical management information available to health professionals and state agencies and retain these records for 10 years from the date of service.