Since the first edition of this book was published, new and revised requirements for the BHC program have been added to address child welfare services, opioid treatment facilities, and substance use programs. In addition, the BHC program has undergone a name change to include human services and address inclusivity. More importantly, recent Joint Commission compliance data has revealed that several elements of performance requiring documentation in this setting are consistently among the most frequently cited higher-hazard requirements for noncompliance.
Because of these changes—and to improve the safety of individuals served—Documentation of Care, Treatment, or Services in Behavioral Health Care and Human Services, Second Edition, offers updated guidance on documenting care, treatment, or services amid dire warnings about the state of mental health in the United States.
Although the COVID-19 pandemic is no longer a public health emergency in the United States, bereavement from loss of loved ones, social isolation during lockdowns, disruptions in employment and work culture, financial instability, and ongoing fear and anxiety due to the unpredictable nature of the COVID-19 virus have taken a toll on individuals’ emotional well-being. In fact, a recent survey by the Kaiser Family Foundation (KFF) and CNN revealed that 90% of adults in the United States believe the country is facing a mental health crisis, three years after the onset of the COVID-19 pandemic.
The goal of this book is to guide BHC organizations at a time when the importance of effective behavioral health care cannot be overstated. Documentation of Care, Treatment, or Services in Behavioral Health Care and Human Services, Second Edition, offers a clear, concise, and accurate reference that breaks down complex concepts into easy-to-digest pieces. This book begins by introducing the basic concepts of documentation in behavioral health care. It then takes an in-depth look at the importance of screening and assessment and finally, concludes with focus on the role of documentation in the planning, delivery, continuity, and discharge or transfer of care, treatment, or services.
Relevant excerpts from the introductions and rationales from Joint Commission BHC standards
Examples of documentation entries that demonstrate appropriate language style and content
Tips and strategies for applying select content to special programs/settings
Sample scenarios that apply a process or approach related to standards and key concepts covered in the text
Dozens of customizable tools, checklists, and forms, including documentation examples
Behavioral health care and human services professionals who create and document plans of care, treatment, and services and record progress and reassessment
Accreditation and certification professionals who review provider documentation to ensure compliance with standards requirements
Performance/quality improvement and risk management professionals
Standards: CTS, IM, LD, NPSG, RC
Settings: Behavioral Health Care and Human Services