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.
3.0 POLICY
3.1 An adequate
medical record should give a pertinent chronological report of the
patient’s evaluation and 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 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 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:
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Acute Medical/Surgical
|
TimeFrames
|
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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)).
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Within 24 hours of admission
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Completed history and physical
examination report
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Within 72 hours of admission
|
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Registered nursing notes
|
End of each shift
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Physician notes
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Daily
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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-day intervals, and at discharge for the
corresponding diagnoses (see the TOM,
Chapter 7, Section 6):
• PTSD - PTSD Checklist (PCL-5).
• Anxiety Disorders - Seven-item
Generalized Anxiety Disorder (GAD-7).
• Depressive Disorders - Patient
Health Questionnaire (PHQ-9 or A).
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)).
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 must
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 calendar day intervals, and
at discharge);
• Treatment planning; and
• Documentation of care.
4.2 The 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-day intervals, and at discharge) for PTSD, anxiety disorders,
and depressive disorders.
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 must 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.