Medical records are a critical service piece for both patients and providers. These records document the health, well-being, medical needs, plan of care, medical necessity and treatment(s) rendered for a patient during their time with a clinician or therapist. This information is frequently reviewed by internal and external medical professionals, patients, and third-party payers. Failure to document information correctly can not only be detrimental to a patient’s care, but it can greatly impact payment for services.
Depending on the specific medical field and payer parties involved, varying documentation requirements may exist. With this in mind, it is imperative to check your local, state, federal, and payer specific requirements before you begin completing paperwork. Being that documentation requirements are not all the same, the safest and most accurate option is to include as much information as possible, along with following stricter guidelines when given the option. ABA and behavioral health fields in the industry still allow for paper documentation to be submitted; however, keep in mind that electronic medical records are becoming the preferred method by payers, along with being the mandatory form of documentation for the medical industry at large.
ABA and behavioral health documentation typically include evidence of the assessment and diagnosis, the ongoing plan of care, and notes of patient progress. This documentation is typically comprised of several records that include session notes and/or progress notes.
Session/progress notes and documents are permanent and legal documents. It is important that these are:
Necessary elements to include in daily session notes:
- Patient’s first and last name
- Patient’s date of birth
- Complete date of service (month, day, year)
- Start and End time
- Place of service (home, office, school, etc.) or note indicating telehealth
- Brief description (narrative form) of the therapy and targeted goal(s)
- Patient’s name and diagnosis must be mentioned in the treatment narrative
- List of any known or unknown allergies
- Legible full legal signature of individual rendering the service
When does documentation need to be completed?
For daily session notes, it is best practice to complete documentation within 24 hours of the session, and no later than 7 days from the date of service. For plan of care or discharge documentation, these should ideally be completed within 7 days of when the patient was last seen, but no more than 30 days beyond that appointment. Certain payers and/or other legal parties may require stricter time frames, so familiarization of these is extremely important.
The storage of records holds equal weight of importance to how they are documented. The Health Insurance Portability and Accountability (HIPAA) act, payer parties, and state confidentiality regulations dictate requirements for record storage. At a minimum, records must be contained in a physically or electronically secure environment for 7-10 years, with the potential for being audited during that time. Records must also be locked and hidden from anyone not involved directly in a patient’s care and should never be stored in a patient’s home.
What if there is an error in a record?
It is important to keep in mind that medical records may cannot be deleted or altered. Records can only be corrected by the original author marking a single line through the error and then initialing and dating beside this; white out and/or black out is not acceptable.
Additional Components that may be required:
- CPT Code or description of service rendered
- Insurance information
- Authorization information
- Supervisor’s Signature
- Patient/Guardian Signature
If you have any further questions about ABA or behavioral health best practices for documentation, please reach out to us at Missing Piece Billing and Consulting. We are always here to help!
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