2.0 BACKGROUND
2.1 The need for thorough medical documentation
for verification of services has been dramatically demonstrated
through the utilization review of services provided to TRICARE beneficiaries,
particularly within various mental health settings. The lack of
pertinent information has often made it impossible to determine
the patient’s clinical condition, actual treatment rendered, the quality
and effectiveness of the care provided, or the identity and qualifications
of the staff providing treatment services.
2.2 Maintenance of accurate individual treatment
records is an essential ingredient in the overall care of the patient.
Medical records serve many important functions and constitute one
of the critical components of any health care delivery system. The
most important function of a medical record is its use as a tool
in the care and treatment of the patient. It serves as the basis
for planning a patient’s care and for the ongoing evaluation of
the patient's condition and treatment. Appropriate documentation
is especially relevant in the field of psychiatry since there are
few objective indicators that validate medical opinions about diagnoses,
response to treatment, and severity of illness.
3.0 POLICY
3.1 An adequate
medical record should give a pertinent chronological report of the
patient’s course of care and should reflect any change in condition
and the results of treatment. All significant information pertaining
to a patient should be incorporated into the patient’s medical record
and be subject to utilization review and quality assurance established
and maintained through the provider’s administration and medical
staff.
3.2 Institutional and
individual professional
providers must maintain adequate contemporaneous clinical records
to substantiate that specific care was actually furnished, was medically
and psychologically necessary
and appropriate, and to identify the individual(s) who provided
the care. The requirements apply to all medical records environments,
both paper-based and computerized or electronic. The minimum requirements
for medical documentation are requirements set forth by either:
• The
cognizant state licensing authority;
• The Joint Commission (TJC) or
authorized accrediting body as determined by the Director, Defense
Health Agency (DHA);
• State standard of
medical practice; or
• 32 CFR 199.
Note: If more
than one of the four standards is applicable, then the strictest
standard is mandatory.
3.3 The medical records for
psychiatric Residential
Treatment Centers (RTCs), acute care psychiatric hospitals, psychiatric
units within acute care institutions,
inpatient/residential
Substance Use Disorder Rehabilitation
Facilities
(SUDRFs),
Partial
Hospitalization
Programs
(PHPs),
Intensive
Outpatient Programs (IOPs), Opioid Treatment Programs (OTPs), and
outpatient
mental health and Substance Use Disorder
(SUD) treatment must, at a minimum, be maintained
in accordance with
TJC,
the
Commission on the Accreditation of Rehabilitation Facilities (CARF),
the Council on Accreditation (CoA), or an accrediting organization
approved by the Director, DHA, along with the requirements
set forth in
paragraph 3.4.
3.4 Due
to the importance of documentation in assuring quality of care and
verification of services, the following are minimum documentation
requirements, along with specific time-frames for their incorporation
into the medical records:
|
Acute
Medical/Surgical
|
TimeFrames
|
|
Admission
evaluation report
For
psychiatric admission evaluation examination report (to include
baseline assessments using standardized measures for the diagnosis
of Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder
(GAD), and Major Depressive Disorder (MDD)).
|
Within 24 hours
of admission
|
|
Completed
history and physical examination report
|
Within 72 hours
of admission
|
|
Registered
nursing notes
|
End of each shift
|
|
Physician
notes
|
Daily
|
3.5 All care rendered and billed
must be appropriately documented in writing. Failure to document the
care billed will result in the claim on specific services or the
claim being denied TRICARE cost-sharing.
3.6 Medical record entries should
be legible and contemporaneous with the clinical event, and benefits
should only be extended for those days for which there is specific
documentation of services.
3.7 Cursory notes of a generalized
nature that do not identify the specific treatment and the patient’s
response to the treatment are not acceptable; e.g., in the case
of individual psychotherapy, a statement that “the patient is still
depressed about the divorce and does not feel ready to face the outside
world” does not adequately document the therapy session. The documentation
should reveal the content of the therapy session, the therapeutic
intervention attempted during the session, and degree of progress
towards established treatment goals.
3.8 Across all behavioral health
settings (outpatient
mental health and SUD,
OTPs,
IOPs, partial hospitalization,
psychiatric RTCs,
and
inpatient/residential SUDRFs),
the following standardized measures will be required at treatment
baseline, at 60-120 day intervals, and at discharge for the corresponding
diagnoses:
• PTSD
- PTSD Checklist (PCL).
• GAD - GAD-7.
• MDD -
Patient Health Questionnaire - 8 (PHQ-8).
3.9 All entries
in the medical records, including paper-based and computerized or
electronic, must be dated and authenticated, and a method must be
established to identify the authors of the entries. When rubber
stamp signatures are authorized, the medical practitioner should
place a signed statement in the facility's administrative files
that he or she is the one who has the stamp and is the only one
who will use it. There shall be no delegation of use of such stamps
to another individual. The provider must authenticate those parts
of the medical records for which he or she has responsibility.
3.10 A pattern
of failure to adequately document medical care will result in episodes
of care being denied TRICARE cost-sharing.
• Application: A pattern
of failure to adequately document professional care may make it impossible
to establish medical necessity in an institutional setting. In this
case, the entire Episode Of Care (EOC) would be denied (both institutional
and professional claims).
3.11 A pattern
of failure to meet minimum documentation requirements may also result
in provider sanctions prescribed under
32 CFR 199.9.
3.12 Certification
of Services
3.12.1 Claims submitted by hospitals (or other authorized
institutional providers) must include the name of the individual
actually rendering the care, along with the individual’s professional
status (e.g., Medical Doctor (MD), PhD, Registered Nurse (RN), etc.).
3.12.2 A participating
professional provider must certify that the specific medical care
listed on the claim form was, in fact, rendered to the specific
beneficiary for which benefits are being claimed, on the specific
date or dates indicated, at the level indicated and by the provider
signing the claim unless the claim otherwise indicates another individual
provided the care. For example, if the claim is signed by a psychiatrist
and the care was rendered by a psychologist or licensed social worker,
the claim must indicate both the name and profession of the individual
who rendered the care.
4.0 POLICY
CONSIDERATIONS
4.1 The psychiatric records should contain four
broad categories of information:
• Administrative information
related to patient identification;
• Assessments obtained
through examination, testing, and observations (to include standardized
assessment measures at baseline, 60-120 day intervals, and at discharge);
• Treatment planning;
and
• Documentation
of care.
4.2 The modern psychiatric record
contains varied types of information produced by a multidisciplinary
group of health care professionals with different types of orientation
and training. This provides an integrated approach by which members
of each discipline jointly develop a comprehensive plan specifying
the responsibility of each discipline.
4.3 The psychiatric record must
include regular progress notes by the clinician that relate to the goals
and objectives outlined in the patient’s treatment plan. This feedback
is essential for guiding members of the therapeutic team. The progress
notes must also contain information to verify that the services
rendered were medically necessary and appropriate. The following
indications are examples of information that should be included
in the progress note to document individual psychotherapy:
4.3.1 The date
of the therapy session.
4.3.2 Length of the therapy session.
4.3.3 A notation
of the patient’s current clinical status evidenced by the patient’s
signs, symptoms, and documentation of standardized assessment measures
(at baseline, at 60-120 day intervals, and at discharge) for PTSD,
GAD, and MDD.
4.3.4 Content of the therapy session.
4.3.5 A statement
summarizing the therapeutic intervention attempted during the therapy session.
4.3.6 Description
of the response to treatment, the outcome of the treatment, and
the response to significant others.
4.3.7 A statement summarizing the
patient’s degree of progress towards the treatment goals.
4.3.8 Progress
notes should intermittently include reference to progress (to include documentation
of standardized assessment measures where applicable) regarding
the discharge plan established early on in the patient’s treatment.