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PBH and NCQA Requirements for Treatment Records and Clinical Documentation Published: October, 2001 Clinical Assessment Treatment Plan Progress Notes Provider Discharge Summary 1. Clinical Assessment The clinical assessment must include all of the following: Special status situations including imminent risk assessment and conservatorship, if appropriate Mental status examination. Presenting problem including relevant psychological and social conditions affecting medical and psychiatric status. Allergies and adverse reactions clearly documented. Lack of known allergies and sensitivities to pharmaceuticals and other substances prominently noted. (i.e.,"NKA") Medical history including current medications and dosages, history of medication trials and results, and relevant medical conditions and their impact on emotional and behavioral functioning. For children and adolescents, prenatal events and developmental history documented. For patients twelve and older, documentation of past and present use of cigarettes, alcohol, illicit, prescribed and over the counter drugs. Assessment of strengths/weaknesses that impact stabilization efforts. Diagnostic impressions using current DSM diagnostic codes, terminology and multi-axial diagnosis. Back to Top 2. Treatment Plan The treatment plan must include all of the following: Treatment plans consistent with diagnoses. Problem statements concerning the primary treatment issues and the focus of the patient's treatment. Treatment goals that are specific, objective, measurable and expressed in behavioral terms. Estimated time frames for goal attainment or problem resolution. Focus of treatment interventions consistent with the treatment plan goals and objectives. Informed consent for medication is documented. Plans for adjunctive treatment and referrals. Signature of therapist. Evidence of patient involvement in and understanding of the treatment planning process through either a patient signature or documentation by the treating clinician. Back to Top 3. Progress Notes Progress notes must include all of the following: Name of the patient. Date of the sessions. Session number. Treatment modality. Problems as defined in the treatment plan are addressed in session. Patient's strengths and limitations are clearly documented in terms of achieving treatment plan goals and objectives and maintaining stabilization over time. Interventions used are consistent with the treatment plan. Outcome of the interventions and/or progress in treatment are clearly documented. For medication management cases, interventions should include documentation of the medications prescribed with doses and frequencies; and treatment outcomes should include responses to and compliance with those medications. Patients who become homicidal, suicidal, or unable to conduct activities of daily living are promptly referred to the appropriate level of care through PBH care management. The treatment record documents preventive services as appropriate, such as relapse prevention, stress management, wellness programs, lifestyle changes, and referrals to community resources. Continued goals/plans for treatment (must be in objective and measurable form). Therapist's signature and degree/license. As applicable, treatment should include the use of homework assignments and compliance with homework assignments should be documented. Documentation reflects continuity of care between prescribing and non-prescribing clinicians, the clinician and the primary care physician, consultants, ancillary providers, and health care institutions; PBH's Health Care Coordination Form has been used to coordinate care with the Primary Care Physician (PCP). Documentation evidences that PBH access standards have been met. Back to Top 4. Provider Discharge Summary The discharge summary must include all of the following: A narrative disposition of the discharge. The dates of follow-up appointments or, as appropriate, a discharge plan which includes appropriate aftercare plans. Back to Top