1. (1) Mental Health Treatment Services shall be documented in a progress note or treatment note in the youth’s Active Mental Health/Substance Abuse Treatment File or mental health section of the youth’s Individual Healthcare Record.

   1. (a) Recording of progress notes/treatment notes shall be carried out either on the day the treatment service/activity is provided or on a weekly basis.

      1. The daily note must be recorded on the Counseling/Therapy Progress Note Form (MHSA 018) or a form developed by the program which contains all the information required in form MHSA 018. The Counseling/Therapy Progress Note Form (MHSA 018, August 2006) is incorporated by reference and is available at HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-03782"
      http://www.flrules.org/Gateway/reference.asp?No=Ref-03782, or may be obtained by contacting: DJJ, Office of Health Services, 2737 Centerview Drive, Tallahassee, FL 32399.

      2. If the progress notes/treatment notes are recorded weekly, the progress note/summary must include the following information:

      a. Summary of the mental health treatment interventions delivered to the youth, based on the youth’s mental health treatment plan,

      b. The youth’s response to the interventions and progress toward reaching individualized treatment goals,

      c. Significant events occurring during the week and contact with family and other agencies,

      d. Signature of the Mental Health Clinical Staff Person who provided the treatment, and the date note was signed.

   2. (b) Documentation requirements for a facility or program designated for Medicaid behavioral health services are set forth by the Agency for Healthcare Administration (AHCA) in the Florida Medicaid Community Behavioral Health Services Coverage and Limitations Handbook.
   3. (c) Documentation of Off-Site Mental Health Treatment which is provided to the facility or program must be filed in the youth’s Individual Healthcare Record or Active Mental Health and Substance Abuse Treatment File.

2. (2) Substance Abuse Treatment Services shall be documented in a progress note/treatment note in the youth’s Active Mental Health/Substance Abuse Treatment File or the substance abuse section of the youth’s Individual Healthcare Record.

   1. (a) Chapter 65D-30 F.A.C., establishes requirements for documentation of substance abuse treatment provided in a facility licensed under Chapter 397, F.S., or by a service provider licensed under Chapter 397, F.S.

   2. (b) In facilities and programs where substance abuse services are provided by a Licensed Qualified Professional, substance abuse progress notes or treatment notes shall be recorded either on the day the treatment service/activity is provided or on a weekly basis.

      1. The daily note must be recorded on the Counseling/Therapy Progress Note Form (MHSA 018) or a form developed by the program which contains all the information required in form MHSA 018.

      2. If the progress notes/treatment notes are recorded weekly, the progress note/summary must include the following information:

      a. Summary of the substance abuse treatment delivered to the youth, based on the youth’s substance abuse treatment plan,

      b. The youth’s response to the interventions and progress toward reaching individualized treatment goals,

      c. Significant events occurring during the week and contact with family and other agencies,

      d. Signature of the Licensed Qualified Professional who provided the treatment and the date note was signed.

   3. (c) Documentation requirements for a facility or program designated for Medicaid behavioral health services are set forth by the Agency for Healthcare Administration (AHCA) in the Florida Medicaid Community Behavioral Health Services Coverage and Limitations Handbook.
   4. (d) Documentation of Off-Site Substance Abuse Treatment which is provided to a facility or program must be permanently filed in the substance abuse section of the youth’s Individual Healthcare Record.

3. (3) Integrated Mental Health and Substance Abuse Treatment shall be documented as follows:

   1. (a) Mental health treatment services shall be documented by the Licensed Mental Health Professional or Mental Health Clinical Staff Person who provided the service.
   2. (b) Concurrent substance abuse treatment shall be documented by the Licensed Qualified Professional or Substance Abuse Clinical Staff Person who provided the service.

Rulemaking Authority 985.64(2) FS. Law Implemented 985.601(3)(a), 985.14(3)(a), 985.145(1), 985.18, 985.48(4),, 985.64(2) FS. History–New 6-20-14.