Improvement Needed in Treatment Record Documentation
The Tristate Care Management Center’s review of 382 provider treatment records between January and December 2007 resulted in an aggregate score of 70 percent compliance with Magellan’s treatment record review standards, which is below our goal of 80 percent.
Records we reviewed were from providers undergoing record review for the first time. The Tristate Care Management Center reviews treatment records of high-volume providers annually. The review of member records allows us to systematically measure compliance with Magellan’s treatment record review standards in order to evaluate and, if necessary, work to improve the quality of care documented by our practitioners.
We ask providers whose records score below the goal of 80 percent to submit improvement plans. Then we subsequently review additional records to evaluate the effectiveness of the plan. In 2007, we reviewed an additional 334 records from providers who were on improvement plans and 90 percent of these records received passing scores.
Opportunities for Improvement
We saw a need for improvement in the areas below. Please review and implement the following recommendations into your treatment records if you’re not already doing so.
Member Rights and Member Confidentiality
Issue: No documentation of the use of member rights and consent forms.
Recommendation: Include a treatment consent form, member rights and an authorization to disclose to primary care physician (PCP) form in the paperwork to be completed by the member at his or her initial visit.
Coordination of Care
Issue: No documentation demonstrating coordination of care with members’ PCP.
Recommendation: Obtain authorization to communicate with the PCP and document contacts with him/her in treatment record notes in the member’s clinical record. (Note: also document member refusals in the treatment record and/or on the authorization form.)
Providers serving Indiana Medicaid members must complete the Hoosier Healthwise treatment sharing form.
Treatment Plan
Issue: Limited documentation regarding treatment goals, time frames for attaining treatment goals, and member’s comprehension of his or her treatment plan.
Recommendation: Establish treatment goals and time frames for achieving treatment goals with the member, discuss the goals and attaining them with the member, and document discussion in treatment record notes in the member’s clinical record.
Progress Notes
Issue: Limited documentation regarding comprehensive education concerning medications prescribed.
Recommendation: Discuss medication importance, compliance and side effects with members who are prescribed medication, and document the discussions in notes.
For further information about Magellan treatment record review standards, refer to the Provider Handbook on this website. If you have questions regarding the record review process, please call Charles Smith, LISW, quality improvement clinical reviewer, at 1-877-212-8656, ext. 65217.