Documentation Resources

CalAIM LMS Trainings

California Advancing and Innovating Medi-Cal (CalAim) is ushering foward adjustments to what DHCS and Medi-Cal are requiring for documentation of services provided to beneficiaries. The documentation training and information supplied on this page will include those CalAim documentation adjustments in addition to documentation standards that will continue.  

In order to obtain further information about CalAim you may visit the following Sonoma County CalAim webpage. 

New Employee Documentation Training

The following trainings and handouts are designed for new Sonoma County clinical staff.

• New Staff Documentation Training Recording
• New Staff Documentation Training PowerPoint
  
  • Activities for coding to 68
  • FSP Procedure Code
  • Location Code Definitions
  • Medi-Cal Certified Sites 
  • Travel Time 
  • Violence Risk Assessment Procedure 
  • Procedure Codes for Client Related Activities 

Documentation Guides

CalMHSA has created documentation guides based on job classification. You can access these manuals, which are updated regularly, on the CalMHSA CalAIM website. 

Assessments

• ANSA CANS Level of Care
• ANSA CANS Summary of Treatment
• Columbia Suicide Severity Rating Scale Presentation

Procedure Codes

• Procedure Codes for Client Related Activities 
• FSP Procedure Code 

Progress Notes

Content & Format

• Concise Notes & Note Content
• Progress Note Clinical Guidance

Targeted Case Management Plan Development

• TCM Plan Development Notes Training Video
• TCM Plan Development Notes Training PowerPoint
• TCM Plan Development Notes PowerPoint Handouts
• TCM Plan Development Sample Notes

Sample Notes

• 301 Targeted Case Management
• 311 Collateral
• 316 Family Therapy
• 331 ANSA & CANS (no client participation)
• 331 ANSA & CANS partially completed
• 331 Initial Intake Assessment
• 341 Individual Therapy
• 345 Therapeutic Behavioral Services (TBS)
• 361ET E&M Medication Support Services
• 361nonEM Non-E&M Medication Support
• 371 Crisis Intervention
• 391 Plan Development for TCM
• 511 Rehab Services (Individual)
• 514 Rehab Services (group)

CSU Documentation

• CSU New Employee Documentation Training Video
• CSU New Employee Documentation Training PowerPoint
• Denial of Rights Documentation Training

Documentation Tips

• Appending vs Deleting
• Connecting Clients to Telehealth
• Consultations & Multiple Providers
• Crisis Intervention
• Discharge Summaries (TCM)
• Documenting Discharge Summaries
• Face to Face Time for Telehealth & Telephone
• Individual Rehabilitation
• Location Field
• No Procedure Code [NPC]
• Respectful & Inclusive Language – Mental Health
• Respectful & Inclusive Language – SUD
• Targeted Case Management (TCM)
• Triennial 2020 Findings for Sonoma County Programs
• Summary of Triennial Findings for Staff & CBOs
• Voicemail & Social Security Paperwork