Treatment Record Review
In support of our commitment to quality care, Magellan of Nebraska requires network providers to maintain organized, well-documented member treatment records that reflect continuity of care. We expect all aspects of treatment to be thoroughly documented in a timely manner, including face-to-face encounters, telephone contacts, clinical findings and interventions, and supervision oversight.
This page includes sample forms required in the member's clinical record. NOTE: Some forms may not be compliant with certain accreditation regulations. It is the provider's responsibility to ensure that documentation is compliant with all applicable regulations and standards specific to their practice.
Initial Diagnostic Interview and Treatment Planning
Progress Notes/Ongoing Treatment
Treatment Record Review User’s Guides and Corrective Action Plan template
Articles Related to Treatment Record Reviews
Coordinating Care for Consumers with Multiple Providers
Many times, members have more than one treatment provider, which can complicate service delivery and pose unnecessary
barriers to progress for the member if not well coordinated. Medicaid regulation calls for coordination efforts amongst treatment providers working with mutual clients and/or families. All professionals involved with members should be aware of other services being provided and active coordination activities should be documented in the member’s treatment record. Specifically,
the treatment plan should clearly identify all clinical interventions being provided including therapy, medication evaluation and management and rehabilitation services and a coordination plan amongst involved clinical practitioners outlined. Additionally, the treatment record should reflect how each clinician serving the member will work in collaboration with each other so that all services delivered will be complimentary and not work in opposition to the other.
Coordination of care efforts are more than simply being aware of the other providers; active coordination requires all treatment providers to participate in meaningful communication and thoughtful planning for the member. This may be especially critical for members who are moving across the treatment continuum. For example, inpatient and residential providers who are preparing members for discharge to the community should be actively working with community providers on transition planning to help support the member’s transfer to lower levels of care.
Likewise, coordination of care between behavioral health and medical providers is also best practice, especially given the prevalence of psychotropic medication oversight that is done by general medical practitioners and the comorbidity of complex medical and behavioral health conditions. As an expectation of Medicaid/Magellan providers, coordination of care efforts are evaluated through the Magellan Quality Improvement retrospective audit process. You can access the Treatment Record Review tool on www.MagellanofNebraska.com by selecting “For Providers” and then the “Treatment Record Review” tab.
Treatment Record Reviews: Signature Guidelines
The Centers for Medicaid & Medicare Services (CMS), the federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, provides quality regulations for providers regarding signatures on documentation. For services rendered, the provider must authenticate documentation, by their signature. The method used must be a hand written or an electronic signature. A handwritten or electronic signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation.
Providers need to know...
- A "Signature on File" statement does not meet signature requirements
- Stamped signatures do not meet signature requirements
- Signatures typed in script font does not meet signature requirements
- Providers need to be aware of the potential for misuse or abuse with electronic signature systems. The software program in use must be set up so that:
- The signer cannot deny having signed the document in the future
- There is verification of the signer's identity at the time the signature was generated; and
- Certainty that the document has not been altered since it was signed.
Nebraska Medicaid Member Rights and Responsibilities (Member Bill of Rights)
Magellan is committed to protecting the rights and responsibilities of all members and having everyone involved in the delivery of care respect the dignity, worth and privacy of each member. We have established members' rights and responsibilities (the Member Bill of Rights) that promote effective behavioral health care delivery and member satisfaction and reflect the dignity, worth and privacy needs of each member.
During Treatment Record Reviews (TRRs), quality reviewers will seek Magellan's Member Rights and Responsibilities Statement that has been signed by both the member and provider and has been retained in the member's record. This provides documented support that the provider reviewed the member's rights and responsibilities during the first appointment and ensures that the member had the opportunity to discuss important care information, such as procedures to follow if a clinical emergency occurs, fees and payments, confidentiality scope and limits, member complaint process, and treatment options and medication.
Magellan's Member Rights & Responsibilities statement is available for distribution in English and Spanish. To find this and other important Treatment Record Review tools, see the Clinical Forms section above.
Treatment Record Practices: Frequent Questions
Network providers are required to maintain organized, well-documented treatment records where all aspects of treatment are documented in a timely manner. For each Medicaid-eligible individual, providers shall keep clinical records that fully disclose the extent of the treatment services rendered and contain documentation sufficient to justify medically necessary treatment that will allow an individual not familiar with the individual to evaluate the course of treatment.
Treatment documentation must be written legibly or typed. If a mistaken entry must be corrected, the recommended approach is to draw a single line through the entry so that it is still readable. The clinician should not use correction fluid or heavy markers. Write the word "mistaken entry" above or beside the original words and place the date and initials next to the entry.
Clinical records must be arranged in a logical order so the clinical information can be reviewed easily, audited and copied. Therapeutic progress notes must be signed and dated by the licensed clinician who rendered treatment services. How long must clinical records for Medicaid members be maintained? Seven years (see 32-001.05, Clinical Records).