MEDICAL RECORD STANDARDS

The following medical standards are based on NCQA medical record standards and represent best practice for documentation for behavioral health providers. These standards will be utilized for medical record reviews completed by St. John's Mercy Managed Behavioral Health staff for the purposes of credentialing, re-credentialing and or quality improvement reviews.

1. Each page in the treatment record contains the client name or ID number
2. Client address, employer or school, home and work telephone numbers including emergency contacts, marital or legal status, appropriate consent forms and guardianship information if relevant is documented.
3. All entries are dated.
4. All entries include the responsible clinician’s name, professional degree and relevant ID number if applicable.
5. The record is legible to someone other than the writer. (A second surveyor examines any record judged to be illegible by one clinical reviewer.)
6. Relevant medical conditions are listed, prominently identified and revised or noted as not present.
7. Medication allergies, adverse reactions (or lack of known allergies) is noted in prominent place.
8. Presenting problems with relevant psychological and social conditions affecting medical/psychiatric status are documented.
9. Special status situations, when present, such as imminent risk of harm, suicidal ideation or elopement potential are prominently noted, documented and revised in compliance with written protocols.
10. Each record indicates what medications are prescribed with dosages of each and the dates of the initial prescription and/or refills. (Refill dates not required in documentation by non-MD practitioners.)
11. Medical and psychiatric history is documented including previous treatment dates, provider identification, therapeutic interventions and responses, sources of clinical data and relevant family information.
12. For children and adolescents, prenatal and perinatal events and developmental history (physical, social, intellectual and academic) must be documented.
13. Clients over the age of 12 years must have documentation of past and present use of cigarettes and alcohol, as well as illicit, prescribed, and over the counter drugs.
14. A mental status exam including presenting problem, risk assessment, mood, affect, memory and speech are documented.
15. A DSM-IV diagnosis is documented consistent with the presenting problems, history and mental status exam.
16. Treatment plans are consistent with diagnosis and include objective and measurable goals with time frames for goal attainment or problem resolution and may include preliminary discharge plan if applicable to client’s condition.
17. Informed consent (education) for medication and diagnosis, and the patient’s understanding of the treatment plan are documented.
18. Progress notes describe client strengths and limitations in achieving treatment plan goals and objectives.
19. Recommendations/referrals for preventative services (support groups, wellness, programs, lifestyle changes) are documented.
20. Appropriate referrals are made for suicidal/homicidal and high risk situations.
21. There is documentation of coordination of care with the primary care physician (PCP).
22. Continuity and coordination of care activities with other Mental Health providers or institutions is documented.
23. Dates of follow up appointments or discharge plan is documented.