CID#
Client Name
Quarter:
Q1
Q2
Q3
Q4
Mental Health Center
MEDICAL RECORDS AND UTILIZATION REVIEW TOOL
ADMINISTRATIVE STANDARDS
1.
CLIENT INFORMATION & AUTHORIZATIONS
1.5
The Client Identification or Overview/Face Sheet tab in the EMR is Complete and
updated as needed.
Voter Registration form is valid and signed for any client who is 18 years or older
– or there is documentation showing that the client was offered the opportunity to
register.
“Vital documents” are written in client’s “language of preference.” If not, there is
a note in the chart indicating that language assistance was provided to assure
client’s understanding of their content.
Consent for Treatment and Evaluation and HIPAA Notice of Privacy Practices
form is completed, signed, witnessed, and dated.
There is evidence that the client received orientation about services at the onset of
treatment and as needed.
1.6
Form to authorize release of information are properly completed and witnessed
1.1
1.2
1.3
1.4
2.
MEDICARE
2.1
Medicare Beneficiaries: There is an ABN signed and dated by the client when
services provided are not covered by Medicare.
2.2
Medicare Recipients: There is a treatment plan signed and dated by the authorized
provider confirming medical necessity prior to providing Medicare-covered
services, including those “incident to.”
2.3
Medicare: There is an initial psychiatric assessment done by an authorized
provider prior to provision of covered services.
3.
PLAN OF CARE (POC)
3.1
POC is signed by the client and/or family member. If not, there is evidence that
the client refused to sign – or there is documentation that the client / family
member participated in the development of the POC.
3.2
POC is signed and dated by the MD within 90 days of the client’s admission or within 45
days if POC includes a rehabilitative service (i.e., RPS, FS, BMod or PSS).
3.3
The POC is reviewed an updated at least annually.
3.4
Services added to the POC and /or increases in the frequency of services and
appropriately authorized by the MD prior to the provision of services.
3.5
Services utilized in treatment are listed on the POC with their appropriate
frequencies.
3.6
Rehabilitative Services were started within 45 days of inclusion on the POC
(i.e., RPS, FS, BMod, or PSS). If not, these were re-authorized.
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4.
CLINICAL SERVICE NOTES
4.1
There is a charge for each legitimate service rendered.
4.2
There is documentation for each service billed.
4.3
Bill times in service notes match actual time billed.
4.4
Dates in service notes match dates they were billed.
5.
5.1
5.2
5.3
5.4
5.5
5.6
MEDICAL STANDARDS
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Non-Medicare Recipients: The initial PMA was provided by a physician within
90 days of admission or on the first service thereafter.
Medicaid Recipients: There is a PMA rendered by the MD before an APRN
delivers a PMA.
MMO: There is a PMA rendered by the MD assigning client to this level of care.
MMO: There is an annual assessment conducted by the MD or APRN to
determine continuation of services at this level of care. If done by the APRN, it is
co-signed by the MD.
MMO: PMO or CSN must contain the following:
a. intervening services since the last PMA
b. assessment of whether client is meeting the goal (s)
c. indication of changes in goal (s)
d. verbal agreement to continue MMO
e. justification for treatment.
MMO: Clients’s progress and any significant changes in treatment are
documented by the MD, APRN, or RN every 90 days or on the first contact
thereafter if client was not seen in the quarter.
6.
MEDICAL RECORDS
6.1
When required, all clinical documents in the medical record are signed/ co-signed,
dated by clinician(s), and include their license and/or degree.
6.2
Abbreviations used on clinical documents are included in DMH/Center approved
Abbreviations List.
CLINICAL STANDARDS
7.
CLINICAL ASSESSMENT
7.1
Initial Clinical Assessment (ICA) was thoroughly completed within three nonemergency visits.
7.2
Primary clinical assessment provides sufficient and appropriate clinical
information to justify the diagnosis according to DMS criteria.
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8.
PLAN OF CARE (POC)
8.1
Transition or Discharge plan is individualized and relevant.
8.2
Treatment goals are expressed in the client’s (family member or guardian, if
appropriate) own words.
8.3
Objectives are written in a way that is understandable to the client based on his/her
development and age.
8.4
Objectives address symptoms/behaviors, including those of co-occurring
disorders, as identified in clinical assessments.
8.5
Objectives are outcome oriented: that is, desired, observable and measurable
behaviors which, once mastered, would lead to achievement of overall treatment
goals.
8.6
Objectives are achievable.
8.7
Objectives are time-specific.
8.8
Treatment interventions are specific and relevant to the treatment objectives.
9.
CLINICAL SERVICE NOTES
9.1
CSNs include all of the following elements:
a. focus of the intervention
(activities, if Rehab groups) that are directly related to a goal / objective on the
ROC.
b. clinician’s interventions
c. client’s response to clinician’s interventions
d. client’s general progress in relation to treatment
e. plan for next session.
9.2
Service Plan Development notes reflect MD and MHP/RN involvement in
a. development, staffing, review, and monitoring of POC or
b. review of outcome data as it impacts diagnosis, treatment, discharge plans, and
focus of types of services, or
c. confirmation of medical necessity, or
d. establishment of dx, and MD recommendation (s)
9.3
9.4
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All services are provided by qualified providers.
Documentation in clinical notes supports services billed.
9.5
Documentation in CSNs/PMOs, including referenced documents, supports bill
time.
9.6
No “non-billable” services were billed (e.g. socialization and recreational
activities) without a clear therapeutic justification.
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10.
TREATMENT PROCESS
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10.1 There is evidence of follow up when client misses an appointment.
There is evidence of inclusion of a family member in treatment for ongoing
10.2 support, when clinically indicated.
10.3 There is evidence treatment focuses on integration of client into the community.
10.4 Progress Summaries are documented every 90 days after admission.
Progress Summary Note includes:
a. review of appropriateness of services and their frequencies
b. review of the client progress on each objective and goal
c. justification for continued treatment
10.5 d. recommendation(s) for continued services
11.
UTILIZATION REVIEW
11.1 There is documentation to justify services as medically necessary.
Services and their frequencies, as planned, are appropriate based on diagnosis,
11.2 needs, and strengths.
11.3 Services are provided within the maximum frequency authorized on the POC.
The frequency and intensity in which services are delivered are appropriate to treat
11.4 the client based on diagnosis, needs, and level of functioning
The clinical interventions effectively treat, relieve, or improve client’s symptoms,
problems, and behaviors OR, in the case of clients who are stable, interventions
11.5 preserve current functioning and/or prevent decompensation.
12.
MEDICAL SERVICES
The Neuroleptic Consent Form is signed and dated by client or guardian and the
prescribing authority when client is prescribed a Neuroleptic or atypical
12.1 antipsychotic medication.
The presence of abnormal movements is assessed and documented at the initiation
of treatment and thereafter every 6 months when the client is prescribed
12.2 antipsychotic medications.
Medication Administration notes include:
a. the name of the medication administered
b. dosage given (quantity and strength)
c. route (IM, ID, IV)
d. injection site
12.3 e. side effects or adverse reactions noted
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12.
PLAN OF CARE (POC)
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Medication-monitoring notes include:
a. the name of the medication (s) client is taking or refers to PMO where
medications are listed
b. side effects or adverse reactions experienced
12.4 c. whether client is refusing or is unable to take medication (s) as order or if
compliant in taking medications as prescribed
d. effectiveness of medications in controlling symptoms
e. issues relating to co-occurring substance use
13.
DISCHARGE/TRANSITION PLAN
Discharge/transition plan include all of the elements listed:
a. date of admission
b. services provided
c. presenting condition
13.1 d. extent to which established goals and objectives were achieved
e. reasons for discharge
f. status of the person served at last contact
g. recommendations for services or supports
h. date of discharge from program
COMMENTS
Standard
Issue
Auditor’s Initials and Date:
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