SOP 508.09-att-1: Mental Health Cover Sheets and Mental Health Record Documentation

SOP 508.09
Attachment 1

03/01/22

# Mental Health Record Section 1

Progress Notes

Progress Notes in DAP Format (D= Data, A = Assessment, P = Plan) [Form M20-02-02]

( _Includes notes made by any member of the treatment team, including_

_counselors, behavior specialists, psychologists, psychiatrists, etc.)_

Non-Adherence Documentation [Form P-33-0003.01]

Group Session Notes [Form M20-01-02]

Mental Health Progress Note [Form M20-02-02/M20-02-02B]

Psychiatric Progress Note [Form M20-02-03]

Discharge Summary Note [Form M32-01-01]

Iso/Seg Progress Notes {48/Weekly or 30/90 day} [Form M40-01-03 or M40-01-04]

ACU Admission /Discharge Summary / Discharge note [Form M70-01-02-05]

CSU Admission/ Discharge Summary/ Discharge Note [FormM70-02, 03, 06, 09]

Mental Health Transfer Summary [Form M80-01-01]

Integrated Treatment Facility (ITF) document – Monthly Summary Report

Page 1 of 9
Form no. M20-01-01

Retention Schedule: Cover sheets shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

SOP 508.09
Attachment 1

03/01/22

# Mental Health Record Section 2

Treatment Plans

Mental Health Diagnosis List [Form M20-01-05]

Initial Treatment Plan [Form M50-01-01]

Comprehensive Treatment Plan [Form M50-01-02]

Comprehensive Treatment Plan Review [Form M50-01-03]

Activity Therapy Assessment and Plan [Form M56-01-01]

Semi-Annual Utilization Review [M27-01-03]

Mental Health Profile Form (Diagnostic Facilities only)

[Form M20-01-03]

Integrated Treatment Facility (ITF) documents – Phase Up Progression Forms

Page 2 of 9
Form no. M20-01-01

Retention Schedule: Cover sheets shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

SOP 508.09
Attachment 1

03/01/22

# Mental Health Record Section 3

Previous Records

Previous Treatment Records

_Including the following:_

_Department of Human Resources Records_
_Private Hospital Records_
_Private Mental Health Professional’s Records_
_Local School System Records_
_Department of Corrections’ Mental Health Records_
_From Prior Incarcerations_

Integrated Treatment Facility (ITF) documents _– Department of Community_
_Supervision (DCS) and other agency documentation_

Copies of DHR or GDC forms used to request the above records

[M31-01-03, Authorization for Release of information]

Page 3 of 9
Form no. M20-01-01

Retention Schedule: Cover sheets shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

SOP 508.09
Attachment 1

03/01/22

# Mental Health Record Section 4

Evaluations

Referral Form [Form M35-01-01] _(Including a copy of the response to the referring_
_party)._
Diagnostic Reception Screen Form [Form M30-01-01]
Mental Health Evaluation for Services Form [Form M31-01-01]

Mental Status Evaluation [Form M31-01-02] when not used as an attachment to
another form (such as a progress note in section 1)

Mental Health related consultations, (e.g. neurological examinations)

Psychiatric / Psychological Evaluations _(Excluding follow-up progress notes)_ _[M60-01-_
_06]_

Psychological Tests Interpretive Reports

Parole Evaluations [M31-01-06]

Physical/Sexual Allegation Evaluations [Form M55-01-03/M55-01-04]

Mental Health Evaluations for Disciplinary Reports [Forms M34-01-01 and M34-01-02]

Behavior Therapy Unit Referral [M57-01-05]

Suicide Risk Assessment [M69-01-01]

Integrated Treatment Facility (ITF) documents – Addiction Severity Index, Four
Quadrants of Care, Learning Experiences (LEs), Staff Awareness documentation, other
evaluations

Page 4 of 9
Form no. M20-01-01

Retention Schedule: Cover sheets shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

SOP 508.09
Attachment 1

03/01/22

# Mental Health Record Section 5

Medico-legal Documentation

Consent to Mental Health Evaluation or Treatment [Form M20-02-01]

Consent to Mental Health Evaluation following a Sexual Allegation [M55-01-02]

Medication Informed Consent [Form M60-01-01]

Release of Information Requests [Form M31-01-03] (When used to grant
authority for Georgia Department of Corrections to release information to
another party)

Involuntary Medication Documents [Forms M66-01-01 thru M66-01-07]

Heat Precautions [Form M60-01-04)

Refusal of Treatment [M20-02-04]

Behavioral Therapy Unit Due Process Committee [M57-01-03/04/08/09/10]

Involuntary Hospitalization [M65-01-04/M65-01-05]

Department of Human Resources Form [Form 1013]

Miscellaneous Medico-legal Documents

Page 5 of 9
Form no. M20-01-01

Retention Schedule: Cover sheets shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

SOP 508.09
Attachment 1

03/01/22

# Mental Health Record Section 6

Physician’s Orders

Copies of Mental Health Related Medication Orders

Copies of Mental Health Related Lab/Medical Procedures Orders

Copies of Mental Health Related Lab/Medical Procedures Reports

AIMs Evaluations [Form M60-01-02]

Page 6 of 9
Form no. M20-01-01

Retention Schedule: Cover sheets shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

SOP 508.09
Attachment 1

03/01/22

# Mental Health Record Section 7

Miscellaneous

Letters, Notes, Cards, Drawings, etc. from the offender to any Mental Health
Staff Member

Letters, etc., to any Mental Health Staff Member from the offender’s Family,
Friends, or Attorney

Copies of Incident Reports _(Except those related to seclusion/restraint)._

Copies of Use of Force Reports _(Except those related to seclusion/restraint)_

Copies of Referral Forms to Community Agencies and/or Transitional Centers for
Post-Release Plans [e.g., M31-01-03; M85-01-01]]

Lockdown Placement Clearance For Protective Custody [ M40-01-02]

Suicide/Self Injurious Behavior [M68-01-09]

Mental Health Related Movement Orders

Miscellaneous Documents

Page 7 of 9
Form no. M20-01-01

Retention Schedule: Cover sheets shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

SOP 508.09
Attachment 1

03/01/22

# Mental Health Record Section 8

Restraints

Copy of Restraints Documentation

_Including the following:_

_Progress notes pertaining to restraint episodes_
_Psychiatrist’s order for restraint [Form M67-01-01]_
_Mental Health professional’s log [Form M67-01-02]_
_Correctional officer/medical staff’s log for restraint [Form M67-01-_
_03]_
_Medical staff/correctional officer’s 24-hour log [Form M67-01-04]_
_Daily notification to the warden [Form M67-01-05]_
_Use of force/incident reports related to restraint._

_(Note: All originals of these documents are to be filed in the medical_
_record, section five.)_

Specialized MH Treatment Unit Admission Form [M-57-01-02]

Specialized MH Treatment Unit Comprehensive Plan [M57-01-07]

Notification to Warden/Superintendent (24-hour Observation) [M68-01-05]

Page 8 of 9
Form no. M20-01-01

Retention Schedule: Cover sheets shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

SOP 508.09
Attachment 1

03/01/22

# Mental Health Record Section 9 INTEGRATED TREATMENT FACILITY (ITF) DOCUMENTS [Overflow from Sections 1 & 4: Group Notes, Learning Experiences (LEs), Staff Awareness documentation, etc]

Page 9 of 9
Form no. M20-01-01

Retention Schedule: Cover sheets shall be placed in the offender’s mental health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.