Michigan
Treatment Record Documentation Improving
In 2007, providers’ overall score on Magellan treatment record reviews was 74 percent. Although this score is below the goal of > 80 percent, it shows improvement from the 2006 overall score of 68 percent. For quality improvement purposes, Magellan generally reviews a sample of provider treatment records annually, using our standardized treatment record auditing tool.
Magellan requires providers to maintain organized, well-documented member treatment records that reflect continuity of care. We expect that all aspects of treatment will be documented in a timely manner, including face-to-face encounters, telephone contacts, clinical findings and interventions.
We identified the following strengths and opportunities in our 2007 review of provider records:
Areas Scoring Well
- Complete initial evaluations, including presenting problems, psychiatric history and medical history
- Comprehensive mental status exams
- Risk factors and special status situations noted.
Areas Needing Improvement
- Member rights and confidentiality elements (signed treatment consent form, signed Patient Bill of Rights, appropriate authorizations to disclose information)
- Substance abuse evaluation for members over age 12, to include nicotine, caffeine, as well as illicit misuse of prescribed and over-the-counter drugs
- Coordination of care (evidence of request for member authorization for primary care physician (PCP) communication, or documentation of member refusal; evidence of PCP communication after the initial evaluation and at other significant points in treatment; and coordination of care between all behavioral health care providers and consultants)
- Estimated timeframes for goal attainment or problem resolution on the treatment plan
- Documentation of member understanding of the treatment plan and medication education.
Providers who fail to meet the treatment record documentation standards receive individualized feedback regarding deficient areas and, when the deficiencies are great enough, a plan of corrective action is implemented and further records are requested to demonstrate compliance.
You can find further information on treatment record documentation in the Magellan Provider Handbook, including our treatment record review tool in Appendix A.