SOP_NUMBER: 508.09-att-1
TITLE: Mental Health Cover Sheets and Mental Health Record Documentation
REFERENCE_CODE: VG20-0001
DIVISION: Mental Health
TOPIC_AREA: 508 Policy - MH Administration/Staff/Certification
EFFECTIVE_DATE: 2022-03-01
WORD_COUNT: 1301
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/667057
URL: https://gps.press/sop-data/508.09-att-1/

SUMMARY:
This attachment establishes the standardized organization and documentation requirements for maintaining offender mental health records within the Georgia Department of Corrections. It specifies eight sections of required documentation including progress notes, treatment plans, evaluations, medico-legal documents, physician orders, and restraint records. Mental health files are retained for 10 years following the end of an offender's need for mental health services or sentence completion.

KEY_TOPICS: mental health records, documentation requirements, treatment plans, progress notes, psychiatric evaluations, consent forms, medication management, involuntary medication, restraints documentation, suicide risk assessment, mental health files, discharge summaries, treatment teams, medical record retention

ATTACHMENTS:
  1. Mental Health Cover Sheets and Mental Health Record Documentation
     URL: https://gps.press/sop-data/508.09-att-1/
  2. Group Treatment Case Notes
     URL: https://gps.press/sop-data/508.09-att-2/
  3. Records Inventory
     URL: https://gps.press/sop-data/508.09-att-3/
  4. Mental Health Diagnosis List
     URL: https://gps.press/sop-data/508.09-att-4/
  5. Group Attendance Roster
     URL: https://gps.press/sop-data/508.09-att-5/

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FULL TEXT:
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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.