TREATMENT RECORD STANDARDS
Providers are required to maintain member records in compliance with the policies and procedures of Carelon and accrediting bodies. Carelon adheres to standards of accrediting organizations such as the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC) and federal and state regulations. These standards require that patient records are maintained in a manner that is current, comprehensive, detailed, organized and legible to promote effective patient care and quality review. Treatment records are subject to audit by accrediting and regulatory authorities as part of Carelon’s accreditation process or regulatory review, and are also subject to random audits by the Carelon Quality Management Department.
Provider participation in random treatment record audits is an integral part of Carelon’s quality management program and is a condition of network participation.
Participating providers are expected to maintain clinical record keeping systems that meet the following basic requirements:
- Consistent with current professional standards;
- In compliance with all the Commonwealth’s regulations;
- Accurately document at least the following on each case for which services are being provided:
- Member information (demographic);
- Clinical information;
- Clinical assessments;
- Treatment plans;
- Services provided;
- Contacts with member’s family, guardians or significant others;
- Treatment outcomes; and
- ASAM for substance abusers;
- The provider shall obtain the member’s consent to release information to the member’s Primary Care Physician (PCP) or documentation of the member’s declination. Providers should supply written notification of diagnostic/treatment services to the PCP and inform the PCP of any prescription for medication. A copy of the written notification to the PCP must be placed in the patient record.
- All members’ treatment records must contain a bio-psychosocial assessment; treatment plan, follow-up assessments, focus of treatment and disposition/discharge plan. Medical and psychological treatment documentation and progress notes must be current and treatment plans shall be updated as necessary for the level of care.
- It is necessary that the provider initiating treatment document an initial treatment plan that describes the active target interventions with specific, measurable goals, and stated in behavioral terms, at the level of care proposed;
- Each page contains the patients name and/or identification number;
- Each record includes the patient’s address, employer or school, home and work telephone numbers, emergency contacts, marital/legal status, appropriate consent forms and guardianship information, if relevant;
- All entries include the responsible clinician’s name, professional degree and relevant identification number, if applicable;
- All entries are dated;
- The record is legible;
- Relevant medical conditions are listed, prominently identified and kept updated;
- Presenting problems and relevant psychological and social conditions affecting the patient’s medical and psychiatric status are documented;
- Special status situations, such as imminent risk of harm or suicidal ideation, are prominently noted, documented and revised in compliance with written protocol;
- Each record indicates what medications have been prescribed, the dosages of each and the dates of initial prescription or refills;
- Allergies and adverse reactions are clearly documented;
- A lack of known allergies and sensitivities to pharmaceuticals and other substances is prominently noted;
- Each record contains copies of confidentiality statements and copies of all signed consents to release information.
- A medical and psychiatric history is documented, including previous treatment dates, provider identification, therapeutic interventions and responses, sources of clinical data, relevant family information, results of laboratory tests and consultation reports;
- For children and adolescents, prenatal events and a complete developmental history (physical, psychological, social, intellectual and academic) are documented;
- For patients 12 and older, documentation includes past and present use of cigarettes and alcohol, as well as illicit, prescribed and over-the-counter drugs;
- A mental status evaluation documents the patient’s affect, speech, mood, thought content, judgment, insight, attention/concentration, memory and impulse control;
- A DSM-IV diagnosis is documented consistent with the presenting problems, history, mental status examination, and/or other assessment data;
- Treatment plans are consistent with diagnoses and have objective, measurable goals and estimated time lines for achieving goals or resolving problems;
- The focus of treatment interventions is consistent with the treatment plan goals and objectives;
- Informed consent for medication and the patient’s understanding of the treatment plan are documented;
- Progress notes describe the patient’s strengths and limitations in achieving treatment plan goals and objectives;
- Record reflects the patients who become homicidal, suicidal or unable to conduct activities of daily living are promptly referred to the appropriate level of care;
- The treatment record documents preventive services as appropriate, such as relapse prevention, stress management, wellness programs, lifestyle changes and referrals to community resources;
- The treatment record reflects continuity and coordination of care between the primary clinician, consultants, ancillary providers and healthcare institutions;
- The treatment record documents dates of follow-up appointments or, as appropriate, discharge plans.
Providers and vendors must, at their own expense, make all records available for audit, review or evaluation by Carelon. Providers shall submit records to Carelon as requested by Carelon within the time frame communicated by Carelon. All mailed records shall be sent to Carelon in the form of accurate, legible, paper copies, unless otherwise indicated prior to submission.