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.