PBH conducts random treatment records audits to assure compliance
with the required documentation standards. These maybe conducted
either via onsite reviews or via mail-in audits. Treatment
record keeping is reviewed for all high volume practitioners
and group practices. In addition treatment record audits maybe
conducted when deficiencies or concerns are identified as
part of the quality improvement process.
Key Points
Treatment records must be kept in a secure area
and they must be well organized.
Required disclosure forms must be present and signed
by the therapist and patient.
Treatment records must contain a clinical assessment,
treatment plan, progress notes and discharge summary
that are consistent with PBH standards.
Notes must reflect that treatment is brief, solution-focused
therapy.
Appropriate referrals and coordination of care
must be clearly documented.
Treatment record audits are conducted on a regular
basis for Preferred Group Practices and individual
practitioners.
