4.2.1 Introduction
4.2.2 References
4.2.3 Scope
4.2.4 Did you know…?
4.2.5 Definitions
4.2.6 Objectives
4.2.7 Procedures
4.2.7-A: Paper or electronic format
4.2.7-B: Retention of records
4.2.7-C: Disclosure of records
4.2.7-D: Comprehensive clinical record
4.2.7-E: Behavioral health provider records
4.2.7-F: Requirements for Community Service Agencies (CSA), Home Care Training to Home Care Client (HCTC) Providers and Habilitation Providers

4.2.1 Introduction
The behavioral health medical record contains clinical information pertaining to a behavioral health recipient. The information assists behavioral health providers in successfully treating and supporting recipients. Maintaining current, accurate and comprehensive behavioral health medical records is important for many reasons. Documentation in the behavioral health medical record facilitates diagnoses and treatment, facilitates coordination of care, supports billing reimbursement information, provides evidence of compliance during periodic medical record reviews and can protect practitioners against potential litigation.

Medical record documentation must be legible, accurate and reflect a behavioral health recipient’s behavioral health status, changes in behavioral health status, and reflect all behavioral health care needs and services provided.

The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) recognizes the value of accurate and comprehensive behavioral health records. ADHS/DBHS, AHCCCS and federal and state authorities establish the standards to guide behavioral health providers in ensuring the proper organization, content, maintenance and retention of behavioral health medical records.

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4.2.2 References
The following citations can serve as additional resources for this content area:

• 45 C.F.R. § 164.502(b)
• 45 C.F.R. § 164.514(d)
• A.R.S. § 12-2291 et. seq
• A.R.S. § 12-2294(C)
• A.R.S. § 36-441
• A.R.S. § 36-445
• A.R.S. § 36-2402
• A.R.S. § 36-2917
• A.A.C. R9-20-211
• A.A.C. R9-21-209
• AHCCCS/ADHS Contract
• ADHS/RBHA Contracts
• ADHS/TRBHA IGAs
• AHCCCS Medical Policy Manual, Policy 940
• Section 3.3, Referral and Intake Process
• Section 3.4, Co-payments
• Section 3.9, Assessment and Service Planning
• Section 3.11, General and Informed Consent to Treatment
• Section 3.12, Advance Directives
• Section 3.14, Securing Services and Prior Authorization
• Section 3.15, Psychotropic Medications: Prescribing and Monitoring
• Section 3.17, Transition of Persons
• Section 3.18, Pre-Petition Screening, Court Ordered Evaluation and Court Ordered Treatment
• Section 3.19, Special Populations
• Section 4.1, Disclosure of Behavioral Health Information
• Section 4.3, Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers
• Section 5.1, Notice Requirements and Appeal Process for title XIX and title XXI Eligible Persons
• Section 5.4, Special Assistance for Persons Determined to have a Serious Mental Illness
• Section 7.4, Reporting of Incidents, Accidents and Deaths
• Section 7.5, Enrollment, Disenrollment and Other Data Submission
• AHDS/DBHS Policy and Procedure Manual Section MI 5.2 Community Service Agencies-Title XIX Certification

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4.2.3 Scope
To whom does this apply?
All providers contracting with a Tribal or Regional Health Authority (T/RBHA) to provide services in Arizona’s public behavioral health system.

4.2.4 Did you know?

• The behavioral health record is the property of the entity that generates the record.
• The Arizona Health Care Cost Containment System (AHCCCS) or its designee may inspect Title XIX and Title XXI behavioral health medical records at any time during regular business hours at the offices of ADHS/DBHS, the T/RBHAs or behavioral health providers.
• The Department of Economic Security, Division of Developmental Disabilities (DES/DDD) or its designee may inspect the behavioral health medical records of their enrolled Title XIX, Title XXI, and DES/DDD Arizona Long Term Care Services (ALTCS) recipients at any time during regular business hours at the offices of ADHS/DBHS, the T/RHBAs, or behavioral health providers.

4.2.5 Definitions
Assessment

Behavioral Health Status

Certification of Need (CON)

Community Service Agency (CSA)

General Consent

Habilitation Provider

Home Care Training to Home Care Client (HCTC) Provider

Informed Consent

Medical Records

Recertification of Need (RON)

Telemedicine

Treatment

4.2.6 Objectives
To ensure that behavioral health records document the delivery of medically necessary services and that each behavioral health record is complete, accurate, legible and current by establishing consistent standards for behavioral health providers.

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4.2.7 Procedures

4.2.7-A. Paper or electronic format
Records may be documented in paper or electronic format.

For paper documentation the record must be:

• Dated;
• Signed with an original signature and credential;
• Legible and either written in blue or black ink or typewritten; and
• Corrected with a line drawn through the incorrect information, a notation that the incorrect information was an error, the date when the correction was made, and the initials of the person altering the record. Correction fluid or tape is not allowed.
• A progress note is documented on the date that an event occurs. Any additional information added to the progress note is identified as a late entry (see A.A.C. R9-20-211(C), Client Records).

For transportation services the following documentation standards apply:

• For providers that supply transportation services for recipients using provider employees (i.e. facility vans, drivers, etc.) the requirements listed above will apply.
• For providers that use contracted transportation services, for non-emergency transport of recipients, that are not direct employees of the provider (i.e. cab companies, shuttle services, etc.) the original signature and credentials portion of these requirements is waived. Instead, documentation for the recipient record must include a summary log of the transportation event received from the transportation provider.

Electronic documentation, including email correspondence, must:

• Indicate the identity of the person making an entry into the record and the date for each entry;
• Ensure that the information is not altered inadvertently;
• Track when, and by whom, revisions to information are made; and
• Maintain a backup system including initial and revised information.

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4.2.7-B: Retention of records
A behavioral health provider must retain the original or copies of a recipient’s medical records as follows:

• For an adult, for at least six (6) years after the last date the adult recipient received medical or health care services from the T/RBHA or behavioral health provider;
• For a child, either for at least three (3) years after the child’s eighteenth birthday or for at least six (6) years after the last date the child received medical or health care services from the T/RBHA or behavioral health provider, whichever occurs later.
  

4.2.7-C: Disclosure of records

• Behavioral health records must be maintained as confidential and must only be disclosed according to the provisions in Section 4.1, Disclosure of Behavioral Health Information.
• Section 4.1, Disclosure of Behavioral Health Information, contains information regarding the review of behavioral health medical records by behavioral health recipients.
• When requested by a recipient’s primary care provider or recipients' DES/DDD/ALTCS support coordinator, the behavioral health record or copies of behavioral health record information must be forwarded within ten (10) days of the request. (See Section 4.3, Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers, for more information.)
• ADHS shall ensure that each recipient is guaranteed the right to request and receive a copy of his/her medical record and to request that they be amended or corrected, as specified in 45 C.F.R. Part 164.

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4.2.7-D. Comprehensive clinical record
The designated behavioral health provider must ensure the development and maintenance of a comprehensive clinical record for each recipient. The comprehensive clinical record, whether electronic or hard copy, may contain information contributed by several other service providers involved with the care and treatment of a recipient.

The comprehensive clinical record must include the following:

• Identification information on each page of the record (i.e., recipient’s name and identification number);
• Documentation of identifying demographics including member’s name, address, telephone number, AHCCCS identification number, gender, age, date of birth, marital status, next of kin, and if applicable, guardian or authorized representative
• Initial history for the member that includes family medical history, social history and laboratory screenings;
• Past medical history for all members that includes disabilities and any previous illnesses or injuries, smoking, alcohol/substance abuse, allergies and adverse reactions to medications, hospitalizations, surgeries and emergent/urgent care received;
• Current problem list/presenting concerns;
• Documentation of any review of behavioral health record information by any person or entity (other than members of the clinical team) that includes the name and credentials of the person reviewing the record, the date of the review and the purpose of the review; and
• The comprehensive clinical record must also contain the following elements listed below. These elements are listed as follows using a system of topics/tabs for purposes of organization and maintenance of required documentation. ADHS/DBHS strongly recommends the use of this system. Clinical records of subcontracted providers of Gila River BHS must contain the required elements. Providers utilize various versions of a clinical record, including electronic record keeping. Therefore, Gila River BHS does not require a provider organize this information in any specific format. Providers are encouraged to utilize ADHS/DBHS recommendations, as applicable.

Intake Paperwork

• For recipients receiving substance abuse treatment services under the Substance Abuse Prevention & Treatment (SAPT) Block Grant, documentation that notice was provided regarding the recipient’s right to receive services from a provider to whose religious character the recipient does not object to. (See Section 3.19, Special Populations);
• Documentation of recipient’s receipt of the Member Handbook and receipt of Notice of Privacy Practice;
• Contact information for the recipient’s primary care provider (PCP), if applicable.

Financial

• Documentation of completed PM Form ADHS AE-01 for initial Title XIX/XXI screening, annual screening and screening conducted when a significant change occurs in a person’s financial status;
• Information (see PM Form 3.4.1, Non-Title XIX/XXI Co-payment Assessment) regarding establishment of any co-payments assessed, if applicable (see Section 3.4, Co-payments).

Legal

• Documentation related to requests for release of information and subsequent releases;
• Copies of any advance directives or mental health power of attorney as defined in Section 3.12. Advance Directives, if applicable including:
  • Documentation in the adult person’s clinical record that the adult person was provided the information on advance directives and whether an advance directive was executed;
  • Documentation of authorization of any health care power of attorney that appoints a designated person to make health care decisions (not including mental health) on behalf of the person if they are found to be incapable of making these decisions;
  • Documentation of authorization of any mental health care power of attorney that appoints a designated person to make behavioral health care decisions on behalf of the person if they are found to be incapable of making these decisions; and
  • Documentation of general and informed consent to treatment pursuant to Section 3.11, General and Informed Consent to Treatment, and Section 3.15, Psychotropic Medications: Prescribing and Monitoring;
  • Authorization to disclose information pursuant to Section 4.1, Disclosure of Behavioral Health Information;
  • Any extension granted for the processing of an appeal must be documented in the case file, including the Notice regarding the extension sent to the recipient and his/her legal guardian or authorized representative if applicable. (See Section 5.1, Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons);
  • For recipients undergoing a voluntary evaluation, as described in Section 3.18, Pre-Petition Screening, Court Ordered Evaluation and Court Ordered Treatment, a copy of the application for voluntary treatment.

Assessments

• Documentation of all information collected in the behavioral health assessment, any applicable addenda and required demographic information (see Section 3.3 Referral and Intake Process, PM 3.9, Assessment and Service Planning, and Section 7.5, Enrollment, Disenrollment and Other Data Submission);
• Documentation of all information collected in the annual update to the behavioral health assessment including any applicable addenda and updated demographic information;
• Diagnostic information including psychiatric, psychological and medical evaluations;
• An English version of the assessment and/or service plan if the documents are completed in Spanish; and
• For recipients receiving services via telemedicine, copies of electronically recorded information of direct, consultative or collateral clinical interviews.

Treatment and Service Plans

• The recipient’s treatment and service plan;
• Child and Family Team (CFT) documentation;
• Progress Notes that include the following:
  • Documentation of the type of services provided;
  • The Diagnosis including an indicator that clearly identifies whether the progress note is for a new diagnosis or the continuation of a previous diagnosis. After a primary diagnosis is identified, the person may be determined to have co-occurring diagnoses. Each provider that the person is referred to for treatment may be addressing a different or new diagnosis. The service providing clinician will place the diagnosis code in the progress note to indicate which diagnosis is being addressed during the provider session. The addition of the progress note diagnosis code (accurate to all digits of the specific DSM-IV code that applies) will help to ensure that diagnostic codes used for the documentation of delivery of services match the codes used on the billing/encounter claim submitted.
  • The date the service was delivered;
  • Duration of the service;
  • A description of what occurred during the provision of the service related to the recipient’s treatment plan;
  • The recipient’s response to service; and
  • For recipients receiving services via telemedicine, electronically recorded information of direct, consultative or collateral clinical interviews.

Medical

• Laboratory, x-ray, and other findings related to the recipient’s behavioral health care;
• Medication record, when applicable; and
• Documentation of Certification of Need (CON) and Re-Certification of Need (RON), (see Section 3.14, Securing Services and Prior Authorization), when applicable.

Reports from other agencies

• Reports from providers of services, consultations, and specialists;
• Emergency/urgent care reports; and
• Hospital discharge summaries.

Correspondence

• Documentation of the provision of diagnostic, treatment, and disposition information (as allowed in Section 4.1, Disclosure of Behavioral Health Information) to the PCP and other providers to promote continuity of care and quality management of the recipient’s health care;
• Letters;
• E-mails, printed out;
• Documentation of any requests for and forwarding of behavioral health record information; and
• Copies of PM Form 5.4.1, Notification of Person in Need of Special Assistance (see Section 5.4, Special Assistance for Persons Determined to have a Serious Mental Illness).

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4.2.7-E. Behavioral health provider records
A recipient may receive behavioral health services from multiple behavioral health providers. Behavioral health providers who are licensed through the Office of Behavioral Health Licensure (OBHL) must maintain a behavioral health record that meets the requirements of A.A.C. 9-20-211. In addition, OBHL licensed behavioral health provider records must include:

• A periodic summary of the recipient’s progress towards treatment goals;
• Physician and practitioner service orders;
• Applicable diagnostic or evaluation documentation;
• Signature/initials of the provider for each service;
• Documentation of adherence to reporting requirements
• For OBHL licensed Level I facilities, documentation that any serious occurrence or death involving a behavioral health recipient (see Section 7.4, Reporting of Incidents, Accidents and Deaths):
  • Has been reported to AHCCCS and the Arizona Center for Disability Law (ACDL);
  • A copy of the information sent to AHCCCS and ACDL; and
  • In the case of a behavioral health recipient’s death that the aforementioned information has been reported to the Center for Medicare and Medicaid Services (CMS).
• Progress notes including:
  • Documentation of the type of services provided;
  • The Diagnosis including an indicator that clearly identifies whether the progress note is for a new diagnosis or the continuation of a previous diagnosis;
  • The date the service was delivered;
  • Duration of the service;
  • A description of what occurred during the provision of the service related to the recipient’s treatment plan; and
  • The recipient’s response to service.
  • In the event that more than one provider simultaneously provides the same service to a behavioral health recipient:
    • Documentation of reasons for the involvement of multiple providers, including the names and roles of each provider involved in the service delivery; and
    • The number of units and amount of time spent for each service provided, consistent with the encounter submission for the service(s);

What information must be forwarded to the recipient’s comprehensive clinical record?
Behavioral health providers must send copies of any information maintained in their own behavioral health record that must also be maintained in the comprehensive clinical record. Subsection 4.2.6-D. describes the elements that must be maintained in the recipient’s comprehensive clinical record.

Transition of Medical Records

Whether it becomes necessary to transfer the behavioral health recipient’s medical records due to transitioning of the behavioral health recipient to a new T/RBHA (see Section 3.17, Transition of Persons, for additional information on Inter-T/RBHA transfers) and/or provider, or the T/RBHA has terminated the provider contract, it is important to ensure that there is minimal disruption to the behavioral health recipient’s care and provision of services. The behavioral health medical record must be transferred in a timely manner that ensures continuity of care.

Is a Written Authorization Required?

Federal and state law allow the transfer of behavioral health medical records from one provider to another, without obtaining the individual’s written authorization if it is for treatment purposes (45 C.F.R. § 164.502(b), 164.514(d) and A.R.S. 12-2294(C). Generally, the only instance in which a provider must obtain written authorization is for the transfer of alcohol/drug and/or communicable disease treatment information (See Section 4.1, Disclosure of Behavioral Health Information for other situations that may require written authorization.

What information must be sent to the new provider?

The original provider must send that portion of the medical record which is necessary to the continuing treatment of the behavioral health recipient. In most cases this includes all communication that are recorded in any form or medium and that relate to patient examination, evaluation or behavioral or mental health treatment. Records include medical records that are prepared by a health care provider or other providers. Records do not include materials that are prepared in connection with utilization review, peer review or quality assurance activities, including records that a health care provider prepares pursuant to section A.R.S. 36-441, 36-445, 36-2402 or 36-2917.

Who retains the original medical record?

Federal privacy law indicates that the Designated Record Set (DRS) is the property of the provider who generates the DRS. Therefore, originals of the medical record are retained by the terminating or transitioning provider in accordance with 4.2.7-B of this Section. The cost of copying and transmitting the medical record to the new provider shall be the responsibility of the transitioning provider (AHCCCS Contractors Operation Manual, Policy 402).

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4.2.7-F. Requirements for Community Service Agencies (CSA), Home Care Training to Home Care Client (HCTC) Providers and Habilitation Providers
The T/RBHA must require that CSA, HCTC Provider and Habilitation Provider clinical records conform to the following standards. Each record entry must be:

• Dated and signed with credentials noted;
• Legible;
• Typed or written in ink; and
• Factual and correct.

If required records are kept in more than one location, the agency/provider shall maintain a list indicating the location of the records.

CSAs, HCTC Providers and Habilitation Providers must maintain a record of the services delivered to each behavioral health recipient. The minimum written requirement for each behavioral health recipient’s record must include:

• The service provided (including the code used for billing the service) and the time increment;
• The date the service was provided;
• The name and title of the person providing the service;
• The recipient’s T/RBHA or CIS identification number and AHCCCS identification number. T/RBHAs must ensure that services provided by the agency/provider are reflected in the behavioral health recipient’s service plan. CSAs, HCTC Providers and Habilitation Providers must keep a copy of each behavioral health recipient’s service plan in the recipient’s record.
• Daily documentation of the service(s) provided and monthly summary of progress toward treatment goals.
• PM Form 4.2.1 is a recommended format that may be utilized to meet the requirements identified in this section.

Every 30 days a summary of the information required in this section must be transmitted from the CSA, HCTC Provider or Habilitation Provider to the recipient’s clinical team or inclusion in the comprehensive clinical record.

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4.2 Behavioral Health Medical Record Standards
Last revised: 05/25/2010
Effective Date: 07/15/2010