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.