Section
4.2 Behavioral Health Medical Record Standards
4.2.1
Introduction
4.2.2 References
4.2.3 Scope
4.2.4 Did you know…?
4.2.5 Objectives
4.2.6 Procedures
4.2.6-A: Paper or electronic format
4.2.6-B: Retention of records
4.2.6-C: Disclosure of records
4.2.6-D: Comprehensive clinical record
4.2.6-E: Behavioral health provider records
4.2.6-F: Requirements for community service
agencies, therapeutic foster care homes for children and habilitation
providers
4.2.1
Introduction
The behavioral health medical record contains a wealth of clinical
information pertaining to the behavioral health recipient; the
information can assist behavioral health providers in successfully
treating and supporting the individual. Maintaining current,
accurate and comprehensive behavioral health medical records for
persons who receive behavioral health services is important for many
reasons. Documentation in the behavioral health medical record
facilitates the diagnosis and treatment of persons, but it also
supports billing reimbursement information, leads to compliance
during periodic medical record reviews and can protect practitioners
against potential litigation.
Medical record
documentation must be legible and accurate and reflect a behavioral
health recipient’s behavioral health status, changes in behavioral
health status, behavioral health care needs and behavioral health
services provided.
ADHS/DBHS recognizes
the value of an accurate and comprehensive behavioral health record.
As such, ADHS/DBHS has established the standards in this section
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:
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4.2.3
Scope
To whom does this apply?
All providers
contracted with a RBHA or TRBHA 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.
- 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.
4.2.5
Objectives
To establish standards to ensure that each behavioral health
record is complete, accurate, legible and current.
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4.2.6
Procedures
4.2.6-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;
- 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; and
- 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 electronic
documentation there must be a method to:
- 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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4.2.6-B:
Retention of records
A behavioral health provider must retain the original or copies
of a person’s medical records as follows:
- For an adult,
for at least 6 years after the last date the adult person received
medical or health care services from the T/RBHA or behavioral
health provider; and
- For a child,
either for at least 3 years after the child’s 18th birthday
or for at least 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.
4.2.6-C:
Disclosure of records
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4.2.6-D.
Comprehensive clinical record
The designated clinical liaison must ensure the development
and maintenance of a comprehensive clinical record for each enrolled
person. The comprehensive clinical record may contain information
contributed by several other service providers involved with the
care and treatment of a person, whether electronic or hard copy. If changes in a person’s clinical
liaison occur, behavioral health providers must ensure that the
person’s comprehensive clinical record is transitioned to
the new clinical liaison (See Section
3.7, Clinical Liaison, and Section
3.17, Transition of Persons).
The comprehensive
clinical record must contain the following elements:
- Documentation
of Title XIX or Title XXI eligibility verification;
- Information
(e.g., PM
Form 3.4.1, Non-Title XIX/XXI Co-payment Assessment)
regarding any co-payments assessed, if applicable (see Section
3.4, Co-payments).
- Contact information
for the person’s primary care provider (PCP), if applicable;
- Identification
information on each page of the record (i.e., person’s name
or identification number);
- Documentation
of all information collected in the Behavioral Health Assessment,
including the Core Assessment, any applicable addenda and required
demographic information (see Section
3.9, Intake, Assessment and Service Planning.)
- An English
version of the assessment and/or service plan if the documents are
completed in Spanish;
- The person’s
treatment and service plan;
- Documentation,
initialed and dated by the person’s clinical liaison to
signify review of:
- Diagnostic
information including psychiatric, psychological and medical
evaluations;
- Reports
from providers of services, consultations and specialists;
- Emergency/urgent
care reports; and
- Hospital
discharge summaries;
- Documentation
of person’s receipt of the Member Handbook and receipt of
Notice of Privacy Practice;
- Copies of
any advance directives or mental health power of attorney as defined
in Section 3.12,
Advance Directives, if applicable;
- 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;
- Documentation
of any review of behavioral health record information by any person
or entity (other than members of the clinical team) which includes
the name and credentials of the person reviewing the record, the
date of the review and the purpose of the review;
- 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 person’s health care;
- For persons
receiving substance abuse treatment services under the SAPT Block
Grant, documentation that notice was provided regarding the person’s
right to receive services from a provider to whose religious character
the person does not object (See Section
3.19, Special Populations); and
- For persons
undergoing a voluntary evaluation, a copy of the application for
voluntary treatment.
- For persons
receiving services via telemedicine, electronically recorded information
of direct, consultative or collateral clinical interviews.
- Discharge
summaries from previous behavioral health treatment;
- Progress
notes;
- Email
printed out;
- Documentation
of Certification of Need and Re-Certification of Need (see Section
3.14, Securing Services and Prior Authorization),
when applicable;
- Laboratory,
x-ray and other findings related to the person’s behavioral
health care;
- Medication
record, when applicable;
- Documentation
of any requests for and forwarding of behavioral health record
information; and
- 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 member.
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4.2.6-E.
Behavioral health provider records
Sometimes, a person may receive behavioral health services from
multiple behavioral health providers. Behavioral health providers
that are licensed through the Office of Behavioral Health Licensure
(OBHL) must maintain a behavioral health record that meets the requirements
of A.A.C. Title 9, Chapter 20 (see
R9-20-211).
In addition, OBHL licensed behavioral health provider records must
include:
- Periodic
summary of the person’s progress towards treatment goals.
- Physician
and practitioner orders for the service;
- 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 date
the service was delivered;
- Duration
of the service;
- A description
of what occurred during the provision of the service related
to the person’s treatment plan;
- The person’s
response to service; and
- 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 person’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 person’s
comprehensive clinical record.
Gila River RBHA
providers must submit the following information to the assigned
Gila River RBHA Clinician/Clinical Liaison:
Level I/Level
II/Level III Behavioral Health Residential Facilities must submit
a monthly staffing summary that includes the following: the person’s
current treatment goals/objectives, progress toward meeting past
treatment goals/objectives, estimated length of stay, remaining
needs to be addressed prior to discharge and barriers to discharge,
if any.
Outpatient Providers
must submit a quarterly summary utilizing the Gila River RBHA Outpatient
Referral/Quarterly Treatment Summary form.
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4.2.6-F.
Requirements for community service agencies, therapeutic foster
care homes for children and habilitation providers
Community Service Agencies, Therapeutic Foster Care Homes for Children,
and Habilitation providers must maintain a record of the services
provided to behavioral health recipients. The minimum written requirement
for each person’s record must include:
- The service
provided and the time increment;
- The date
the service was provided;
- The name
of the person providing the service; and
- A mechanism
to track this information to the encounter, as well as to the
person’s comprehensive clinical record (PM
Form 4.2.1, Clinical Record Documentation Form, may
be used as a mechanism to capture this information).
Every 30 days a
summary of the person’s clinical progress must
be transmitted from the Community Service Agency, the Therapeutic
Foster Care Home for Children, or the Habilitation provider to the
person’s assigned clinical liaison.
PM Form 4.2.1,
Clinical Record Documentation Form, may be used as a monthly
summary.
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4.2
Behavioral Health Medical Record Standards
Last revised: 03/15/2006
Effective Date: 10/01/2006 |
