Client file
The client file includes all client information. The client file includes all client information (some of this information may be in the SSIS information system).
Adult MH-TCM agencies must follow these additional requirements:
- Releases of information.
- Functional assessments.
- Mandated screenings and level of care documentation.
- ICSPs.
- Client contact/progress notes of MH-TCM services provided to the client
- Entries of any assessment/planning/referral/monitoring coordination activities/communication that the case manager has engaged in on behalf of the client with family members, significant others, other providers of services, representatives of other community resources, and/or the clients natural supports - with or without client; whether coordination/communication was initiated by case manager or another (e.g. calls from client family members).
- Documentation of clinical supervision by the clinical supervisor; such as, review of the client’s record/file and “case review” between the case manager and clinical supervisor.