County of Marin Health and Human Services

Clinical Documentation Guide

This manual has been developed as a resource for providers of BHRS. It outlines documentation standards and practices required within the Children, Youth and Family System of Care, Adult/Older Adult System of Care, contract providers, and Substance Use Services. It serves to ensure that providers within BHRS meet regulatory and compliance standards of competency, accuracy, and integrity in the provision and documentation of their services.

Download the BHRS Clinical Documentation Guide

Navigating this documentation guide:

  • Clicking on a subject in the Table of Contents will take you to that subject.
  • Use the up and down arrows or the Page Up and Page Down on your keyboard to scroll.
  • Use the left and right keys on your keyboard to go from page to page.
  • Use the Home key on your keyboard to return to the title page.

Mental Health and Substance Use Services (MHSUS) changed its name to Behavioral Health and Recovery Services (BHRS).  As such, all references in existing departmental policies and procedures to MHSUS can be understood to reference BHRS as well.

BHRS Clinical Documentation Guide Feedback Form

Please do not include sensitive information such as social security numbers, client names or other identifying information.

Documents

PDF icon 2022 Clinical Documentation Guide

Clinical Documentation Trainings