SMHS Resource Library

Payment Reform Reminder and Updates

• Payment Reform Updates

County and Contract Forms and Resource Library

• Chart Review Protocol
• JV220 Application (typically for SSA or Probation Staff to complete)
• JV220A
• JV220B
• QA/QI Trainings and Documentation Support

Sample County and Contract Provider's Documentation

• County EHR Biopsychosocial (County)
• Sample Psychological Testing Report

Sample County EHR 7 Domain Assessments

• County EHR Central Client 1 - 7 Domain Assessment
• County EHR Central Client 1 - ICC-IHBS Care Plan Progress Note
• County EHR Central Client 1 - Problem List Update
• County EHR Regional Client 2 - 7 Domain Assessment
• County EHR Regional Client 2 - ICC-IHBS Care Plan Progress Note
• County EHR Regional Client 2 - Problem List Update
• County EHR Regional Client 2 - Certified Peer Support Specialist Plan of Care Progress Note
• County EHR Central Client 3 - 7 Domain Assessment (CEGU)
• County EHR Central Client 3 - 7 Domain Re-Assessment (CEGU)
• County EHR Central Client 3 - ICC-IHBS Care Plan Progress Note
• County EHR Central Client 3 - ICC-IHBS Care Plan Progress Note Re-Assessment
• County EHR Central Client 3 - Problem List Update
• County EHR Regional Client 4 - 7 Domain Assessment (Juvenile Justice)
• County EHR Regional Client 4 - ICC-IHBS Care Plan Progress Note
• County EHR Regional Client 4 - Problem List Update
• County EHR Regional Client 4 - Certified Peer Support Specialist Plan of Care Progress Note

Sample Contract Provider's 7 Domain Assessments

• Central Contract Provider Client 1 - 7 Domain Assessment (Child Welfare)
• Central Contract Provider Client 1 - ICC-IHBS Care Plan Progress Note
• Central Contract Provider Client 1 - Problem List Update (Child Welfare)
• Regional Contract Provider Client 2 - 7 Domain Assessment
• Regional Contract Provider Client 2 ICC-IHBS Care Plan Progress Note
• Regional Contract Provider Client 2 Certified Peer Support Specialist Plan of Care Progress Note
• Regional Contract Provider Client 2 - Problem List Update
• Regional Contract Provider Client 3 - 7 Domain Assessment (TAY & Juvenile Justice)
• Regional Contract Provider Client 3 - ICC-IHBS Care Plan Progress Note
• Regional Contract Provider Partners Client 3 Certified Peer Support Specialist Plan of Care Progress Note
• Regional Contract Provider Client 3 - Problem List Update (TAY & Juvenile Justice)

Blank Forms

• County (Downtime Form) and Contract Provider Blank 7 Domain Assessment Form
• County (Downtime Form) and Contract Provider Blank Problem List
• County (Downtime Form) and Contract Provider Blank TCM Care Plan Progress Note
• County (Downtime Form) and Contract Provider ICC Care Plan and IHBS Authorization Form Progress Note
• County (Downtime Form) and Contract Provider Blank Encounter Document and Progress Note Form

Sample County Progress Notes

EHR Chart 1 Progress Notes

• County EHR Client 1 Intake Note
• County EHR Client 1 - Domain 7 Assessment Write-Up (no client present)
• County EHR Client 1 Comprehensive Multidisciplinary Evaluation by MHW
• County EHR Client 1 Comprehensive Multidisciplinary Evaluation by Therapist
• County EHR Client 1 External Record Review Assessment Note
• County EHR Client 1 Bief Emotional/Behavioral Assessment
• County EHR Client 1 Individual Therapy Note
• County EHR Client 1 ICC 90 Day CFT Review Note
• County EHR Client 1 IHBS Note
• County EHR Client 1 IHBS Collateral Note
• County EHR Client 1 Community Based WRAP Service

EHR Chart 2 Progress Notes

• County EHR Client 2 Intake Note
• County EHR Client 2 Assessment External Record Review Note
• County EHR Client 2 Assessment Psych_Testing_w-add-on
• County EHR Client 2 Telephone Assessment
• County EHR Client 2 Domain 7 Assessment Write-Up (no client present)
• County EHR Client 2 Individual Therapy Note with Interpretation Psychiatric Results
• County EHR Client 2 Individual Therapy (EMDR) Note
• County EHR Client 2 Family Therapy Note
• County EHR Client 2 ICC Note
• County EHR Client 2 ICC 90 Day IS Review Note
• County EHR Client 2 IHBS Note
• County EHR Client 2 Certified Peer Support Specialist Progress Note

EHR Chart 3 Progress Notes

• County EHR Client 3 Intake Note
• County EHR Client 3 Assessment Note with Oral Translation
• County EHR Client 3 Assessment External Record Review Note
• County EHR Client 3 Assessment Psychological Testing with add-on code note
• County EHR Client 3 Domain 7 Assessment Write-Up (no client present)
• County EHR Client 3 Individual Therapy Note
• County EHR Client 3 Individual Therapy with Interactive Complexity Note
• County EHR Client 3 Crisis Psychotherapy Note
• County EHR Client 3 ICC 90 Day CFT Review Note
• County EHR Client 3 IHBS Note
• County EHR Client 3 Med Team Conference Note
• County EHR Client 3 Plan Development Consult Note

EHR Chart 4 Progress Notes

• County EHR Client 4 Intake Note
• County EHR Client 4 Individual Therapy Note
• County EHR Client 4 Family Therapy Note
• County EHR Client 4 ICC 90 Day IS Review Note
• County EHR Client 4 IHBS Note
• County EHR Client 4 Certified Peer Support Specialist Progress Note

Sample Contract Progress Notes (Paper format)

Chart 1 Progress Notes

• Client 1 Contract Provider (Central) Intake Note
• Client 1 Contract Provider (Central) Brief_Emotional/Behavioral Assessment (Screening tool)
• Client 1 Contract Provider (Central) Comprehensive Multidisciplinary Evaluation by MHW (more than 1 provider)
• Client 1 Contract Provider (Central) Comprehensive Multidisciplinary Evaluation by Therapist (more than 1 provider)
• Client 1 Contract Provider (Central) Assessment Interpretation of External Records Review
• Client 1 Contract Provider (Central) 7 Domain Assessment Write-up (no client present)
• Client 1 Contract Provider (Central) Individual Therapy Progress Note
• Client 1 Contract Provider (Central) ICC 90 day CFT review Progress Note
• Client 1 Contract Provider (Central) IHBS WRAP Progress Note
• Client 1 Contract Provider (Central) IHBS Collateral Progress Note
• Client 1 Contract Provider (Central) Community Based Wraparound Service Progress Note

Chart 2 Progress Notes

• Client 2 Contract Provider (Regional) Intake Note
• Client 2 Contract Provider (Regional) Assessment External Record Review
• Client 2 Contract Provider (Regional) Assessment Psychological Testing with add-on code
• Client 2 Contract Provider (Regional) Telephone Assessment Note
• Client 2 Contract Provider (Regional) 7 Domain Assessment Write-up (no client present)
• Client 2 Contract Provider (Regional) Individual Therapy Progress Note
• Client 2 Contract Provider (Regional) Individual Therapy EMDR Progress Note
• Client 2 Contract Provider (Regional) Family Therapy Progress Note
• Client 2 Contract Provider (Regional) ICC Progress Note
• Client 2 Contract Provider (Regional) ICC 90 day I.S. review Progress Note
• Client 2 Contract Provider (Regional) IHBS Progress Note
• Client 2 Contract Provider (Regional) Certified Peer Support Specialist Progress Note

Chart 3 Progress Notes

• Client 3 Contract Provider (Regional) Intake Note
• Client 3 Contract Provider (Regional) Individual Therapy Progress Note
• Client 3 Contract Provider (Regional) Family Therapy Progress Note
• Client 3 Contract Provider (Regional) ICC 90 day I.S. review Progress Note
• Client 3 Contract Provider (Regional) IHBS Progress Note
• Client 3 Contract Provider (Regional) Certified Peer Support Specialist Progress Note

Sample Contract STRTP Assessment & Progress Notes (Paper format)

• Contract STRTP Sample Assessment Intake Note
• Contract STRTP Sample Assessment Write-Up Note by LPHA using 70899-418 (no client present)
• Contract STRTP Sample Assessment Evaluation
• Contract STRTP Sample Individual Therapy Note
• Contract STRTP Sample Crisis Psychotherapy Note
• Contract STRTP Sample Collateral Rehab Note
• Contract STRTP Sample IHBS Note
• Contract STRTP Sample IHBS 2nd Note
• Contract STRTP ICC CFT Note
• Contract STRTP Care Management Progress Note for MD
• Contract STRTP Oral Medication Administration, Direct Observation, 15 min.
• Contract STRTP Problem List Update