Medi-Cal Coding and Documentation Requirements

Documentation Standards

Mental Health Progress Notes

All entries in the client record will include:

•Date of service delivery (00/00/00);

•Identify the type of MH service delivered;

•Location of Service;

•Duration/Length of Service in minutes (with sufficient documentation to justify the time expended);

•Signature of the person providing the service (or electronic equivalent) and co-signature, if applicable;

•Service provider’s professional degree, licensure, job title and;

•Relevant identification number, if applicable.