Medical records are a critical service piece for 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 can also greatly impact payment for services.
Documentation requirements vary depending on the specific medical field and payer parties involved. With this in mind, it is imperative to check your local, state, federal and payer-specific requirements before you begin completing paperwork. Given that documentation requirements are not all the same, the safest and most accurate option is to include as much information as possible and to follow stricter guidelines when given the option. ABA and behavioral health services in the industry still allow for the submission of paper documentation. However, keep in mind that payers are increasingly preferring electronic medical records as the mandatory form of documentation for the medical industry at large.
ABA and behavioral health documentation normally include evidence of the assessment and diagnosis, the ongoing plan of care and notes of patient progress. This documentation typically comprises several records, which include session notes and/or progress notes that were taken during ABA consultations and the provision of services.
It is important that session/progress notes and documents are:
- Legible
- Accurate
- Timely
- Clear
- Concise
- Complete
- Truthful
Necessary elements to include in daily session notes include:
- The patient’s first and last name
- The patient’s date of birth
- Complete date of service (month, day, year)
- Start and end time and dates
- Diagnosis
- Place of service (home, office, school, etc.) or note indicating telehealth
- Brief description (narrative form) of the therapy and targeted goal(s)
- The patient’s name and diagnosis must be mentioned in the treatment narrative
- List of any known or unknown allergies
- Legible full legal signature of the individual rendering the service
When does documentation need to be completed?
In both public and private ABA therapy settings, it is best practice to complete daily session notes within 24 hours of the session and no later than seven days from the date of service. Plan of care or discharge documentation should ideally be completed within seven days from when the patient was last seen, but no more than 30 days after that appointment. Certain payers and/or other legal parties may have stricter time frames, so familiarity with these is extremely important for ABA benefit and authorization management.
Record storage
The storage of records is just as important as the way in which 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 possibility of being audited during that time. Records must also be locked and hidden from anyone not directly involved 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 cannot be deleted or altered. Records can only be corrected by the original author marking a single line through the error and initialing and dating the correction. White outs and/or black outs are 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
Reach out to Your Missing Piece
If you have any further questions about ABA agency or behavioral health best practices for documentation, contact us at Missing Piece Billing and Consulting. We are always here to help!