Improvement Needed in Treatment Record Documentation
Each year, Magellan audits member treatment records documented and maintained by our network practitioners. This systematic review measures practitioner compliance with our treatment record standards to evaluate and, if necessary, work to resolve issues that may impede the quality or success of member treatment. In addition to the annual review, we conduct treatment record audits whenever significant quality-of-care issues arise.
The review by our California Care Management Center of 76 provider treatment records between January and December 2009 resulted in an aggregate score of 78 percent compliance with Magellan’s treatment record standards—reflecting a slight decrease from the 2008 result of 83 percent. Especially given this drop in compliance with our treatment record standards, we continue to ask providers with scores below the minimum of 70 percent to submit improvement plans.
Areas of Focus
As part of the treatment record review process, we evaluate eight primary categories:
- general information
- member rights and member confidentiality
- initial evaluation
- coordination of care
- treatment plan
- progress noted in treatment
- medication (applies to psychiatrists)
- referral/outreach
Magellan congratulates providers for high scores in documenting medication and referral/outreach. However, the audit also revealed room for improvement in the areas discussed below.
Opportunities for Improvement
As a result of scores below 70 percent, follow-up treatment record reviews of 10 high volume providers on improvement plans will be conducted in 2010. Furthermore, the areas listed below remain out of compliance by nearly all providers. Please review and implement the accompanying recommendations in your treatment records.
Treatment Plan
Issue: No documentation of the treatment plan.
Recommendation: Include documentation of your treatment plan in your treatment record. The treatment plan should include the targeted issues of treatment, specific goals and objectives, and interventions you will employ to assist the member.
Coordination of Care
Issue: No documentation demonstrating coordination of care with members’ PCPs.
Recommendation: Include a treatment consent form, member rights statement and an authorization to disclose PHI to primary care physician (PCP) form in the paperwork to be reviewed and signed by the member at his or her initial visit. (Note: If the member refuses to authorize communication with the PCP, document member refusal in the treatment record and/or on the authorization form, and have the member sign the documentation).
For further information about Magellan treatment record standards, refer to the Provider Handbook and the California Provider Supplement on this website. If you have questions regarding the record review process, please contact Pam Masters at 310-726-7121 or PJMasters@MagellanHealth.com.