Based on BHIN 25-024 – Interim Regulations for Licensure of Psychiatric Residential Treatment Facilities that was released on June 23, 2025. It outlines the EHR documentation needed to meet the requirements to demonstrate medical necessity, concurrent review, and claimable services.
Most of the EHR documentation information can be found in CalMHSA Inpatient website. Please visit for more details.
Below are the recommendations for where/how to document to meet this BHIN requirements:
1. Assessments
- Assessments should follow standard inpatient/residential protocols.
- Each provider completes their respective assessment using the following note templates and procedure code, determined appropriate by the county
- Each provider signs their own assessment. Providers may optionally add co-signers (e.g., treatment team members),percounty policies.
Provider | EHR Location/Form | Notes |
Doctors/Nurses | Services/Notes | Use procedure codes that are assigned with the Psych/Medical Note Template |
Clinicians | CalAIM Assessment |
|
** Ensure all required BHIN 25-024 elements are included.
2. Admissions
- Admission Agreements are completed on paper (facility-specific) and scanned into the EHR under Admission Documents after being signed by all required parties.
- Admission Orders are entered in Client Orders, following the same process as inpatient admissions.
3. Treatment Planning
- The Interdisciplinary Treatment Plan (ITP) can be used by multiple care team members. Ensure a ‘golden thread’ connects assessments, identified problems, goals, and interventions.
- Document consultations with external partners (e.g., Social Worker, Probation, ICWA) in Progress Notes or in the ITP.
- Include a discharge planning goal with anticipated length of stay.
- **For 2026 development CalMHSA is working on a new Shared Treatment Plan that will have a distinct field for discharge planning.
4. Medications
- New or modified medications with justification of use and/or how it relates to client goals, should be documented in progress notes.
- Response to medications, side effects, adverse reactions should be captured in client’s allergies, progress notes, treatment plans, discharge summaries as deemed clinically appropriate by providers.
- Medication consents can be captured in progress notes and a compiled summary care be found in the CalMHSA 116 Medication Consent from Psych Note Template Report.
5. Seclusion & Restraint (S&R)
- Document S&R incidents in the existing S&R module. Follow the same process used for IP/CSU/Res programs.
6. Discharge Planning and Documentation
Discharge Orders are entered in Client Orders, following the same process as inpatient discharge.
CalMHSA Discharge/Transfer Summary can be used to capture:
- Reason for Admission in Episode Summary section
- Type of setting being discharged in the Discharge Plan section
- Course of treatment in Episode Summary section
- Referrals and supports in Discharge Plan section
- Medication plan in the Discharge Plan section
- Medication changes and reviews in Episode Summary or Prognosis sections, as well as individual progress notes or in the treatment plan.
Discharge Instructions (client version) should be reviewed with the client before providing a copy to the client.
- Documentation of patient receiving discharge instructions can be captured in Progress Note or CalMHSA Discharge/Transfer Summary under Other Important Information section per county policies.
CalMHSA 119 Aftercare/Discharge/Transfer Summaries Report compiles medical information and CalMHSA Discharge/Transfer Summaries as a report that can be shared with other providers/clients.
7. Incident Reporting
- Complete Incident Reports using the standard IR workflow. Include all required notifications and follow-up documentation per policy.
8. Compliance & Quality Review
Supervisors should audit records to ensure:
- Assessments include all BHIN 25-024-required elements
- Treatment and discharge documentation demonstrate a clear ‘golden thread’
- Admission and discharge orders are properly entered in Client Orders
- Required signatures from all relevant stakeholders and scanned documents are present in the chart.
10. Summary
Task | EHR Location/Form | Notes |
Timeliness Tracking | Can use tracking protocols | Most be enforced by county policies |
Admission Agreements | Paper | Scan into client chart |
Admission Orders | Client Orders | Use “Admission Order” |
Assessments | Services/Notes or CalAIM Assessments | Determined by role |
Treatment Plan | Interdisciplinary Treatment Plan | Multiple authors can contribute |
Seclusion and Restraints | Client Orders |
|
Discharge | CalMHSA Discharge or CalMHSA Transfer Summary, which then pushes data to the CalMHSA 119 Report
Discharge Instructions is for clients. | Include: Type of setting Course of treatment Referrals and supports Medication plan and changes |