Documentation is an important aspect of compliance. To improve documentation, consider the following recommendations, courtesy of Anne Fisk and Mary Beth Thomas (“Regulatory Compliance Issues in Behavioral Health,” Journal for Healthcare Quality, 2003; (133))
- A chart entry must describe the service, as well as justify it.
- The progress note documentation must be legible, and must include:
o The date and duration of the session
o A description of the nature of the treatment service
o The patient’s response to the therapeutic intervention
o A plan
- Progress notes should contain recommendations for revisions in the treatment plan and an assessment of the patient’s response to treatment and progress in meeting the goals set forth in the original treatment plan.
- The medical record must specify the psychiatric components of the record.
- The content requirements for admission documentation are spelled out, as are the expectations for the treatment plan and progress notes.
And always…confirmation of pre-authorizations as necessary!