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Run: Behavioral Health Integration Collaborative Care Documentation Template

Behavioral Health Integration Collaborative Care Documentation Template for recording CoCM eligibility, care manager time, psychiatric consultation, registry...

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Submission Notice

Documentation Period (required)

Select the month or date range this collaborative care entry covers.

Entry Type (required)

Choose the type of documentation being completed.

Patient consent for collaborative care obtained? (required)

Document whether consent or disclosure required by your workflow has been completed.

Consent Date

Enter the date consent was obtained if applicable.

Patient Identifier

Use your organization’s approved identifier only if needed for registry linkage. Avoid collecting unnecessary PII.

Patient and Program Eligibility

Care Setting (required)

Primary Behavioral Health Concern (required)

Registry Status (required)

Treatment Goal Summary

Briefly summarize the current care goals, using only the minimum necessary detail.

Care Manager Time and Activities

Behavioral Health Care Manager Minutes (required)

Enter the total minutes spent on CoCM activities during the billing period.

Number of Care Coordination Contacts

Count patient, family, or care team contacts related to collaborative care.

Activities Completed (required)

Select all collaborative care activities completed during this period.

Care Manager Notes

Document clinically relevant coordination details, using minimum necessary information.

Psychiatric Consultation

Psychiatric consultation completed? (required)

Consultation Date

Consultant Recommendation Summary

Summarize recommendations, medication guidance, or care plan changes.

Recommendation implemented?

Registry Tracking and Billing Support

Registry Review Date

Symptom Measure Used

Select the measure used for registry tracking if applicable.

Current Measure Score

Billing Code (required)

Billing Rationale

Briefly explain how the documented activities support the selected billing code.

Attestation and Audit Trail

Documented By (required)

Enter the role or name of the staff member completing this form, per organizational policy.

Attestation (required)

Yes No N/A

Follow-up needed? (required)

Follow-up Details

Describe the next action, owner, and due date if follow-up is needed.

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