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CLINICAL
DOCUMENTATION
GUIDE
2018BEHAVIORAL HEALTH AND RECOVERY SERVICES
BARS Documentation Manual v 1/17/2018CONTENTS
1INTRODUCTION/COMPLIANCE1.1Why Do We Have This Manual?51.2Compliance62GENERAL
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What is general principles of documentation?
General principles of documentation refer to the basic guidelines and standards that govern how information should be recorded and organized in written or electronic form.
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All individuals, organizations, or businesses that are involved in documenting information for legal, regulatory, or operational purposes are required to follow general principles of documentation.
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General principles of documentation should be filled out using clear, accurate, and objective language, following the established guidelines and standards for documentation in a specific industry or field.
What is the purpose of general principles of documentation?
The purpose of general principles of documentation is to ensure the accuracy, consistency, and reliability of recorded information, making it easier to retrieve, share, and analyze data as needed.
What information must be reported on general principles of documentation?
General principles of documentation typically require information such as dates, names, descriptions, observations, and any other relevant details that help to document and explain a particular event, transaction, or process.
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