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8.6 Documentation Requirements
Client record documentation must support medical necessity for the services provided and must be maintained and made readily available for review when requested by the Health and Human Services Commission (HHSC) or its designee. SBIRT documentation must include the following:
• An indication that the client has an alcohol- or drug related traumatic injury or condition
•Positive screening by a standardized substance-abuse screening tool
•Laboratory results, such as blood alcohol content, toxicology screen, or other measures, that show at least a moderate risk for substance abuse
•If a referral is made, the name, address, and telephone number of the provider to whom the client was referred
•A written, client-centered plan for the delivery of medically necessary SBIRT. The plan must be completed at the time the client is admitted to the second session (referral). The plan must include the following:
•Real-life goals expected
•Strategies to achieve the goals
•Support system such as family members, a legal guardian, friends, or anyone the client identifies as important to them
•A mechanism for following up with the client to ensure that the client keeps appointments for additional sessions
The provider who performed the screening must document that a follow-up appointment was made for a subsequent session.
If inappropriate payments are identified on retrospective review for any provider, the payments will be recouped.
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