Summary: Documentation Review Dr. Dawn-Elise Snipes PhD, LPC-MHSP Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review Addiction Counselor Certification Training (400 Hours) $149 Documenting the Treatment Process ~ The client record is the most important tool to ensure continuity of care ~ Documentation contributes to service delivery by: ~ Reducing replication of services ~ Presenting a cohesive longitudinal record of clinically meaningful information ~ Ensuring reimbursement for services ~ Assists in guarding against malpractice ~ What was done ~ By whom ~ Were they adequately credentialed Purposes of Clinical Documentation ~ Records professional services ~ Intake ~ Differential diagnosis ~ Placement criteria used in decision making ~ Treatment and other services provided ~ Response to treatment interventions ~ Referral services and outcome ~ Clinical course ~ Reassessment and treatment plan reviews ~ Records compliance with state, accreditation and payor requirements ~ Ease transition to other programs and to referral resources ~ Prevent duplication of information gathering when possible Purposes of Clinical Documentation ~ Facilitates Quality Assurance ~ Documenting the appropriateness, clinical necessity and effectiveness of treatment ~ Substantiating the need for further assessment and testing ~ Support termination or transfer of services ~ Identifying problems with service delivery by providing data to support corrective actions ~ Adding to methods to improve and assure quality of care ~ Providing information that is used in policy development, program planning and research ~ Providing data for use in planning professional development activities. ~ Fosters communication and collaboration between multidisciplinary team members Documentation: CFR 42 part 2 ~ Confidentiality of Alcohol and Drug Abuse Patient Records ~ 42 CFR Part 2 applies to all records relating to the identity, diagnosis, prognosis, or treatment of any patient in a substance abuse program in the US ~ Prohibition, data that would identify a patient as suffering from a SUD or undergoing SUD treatment ~ 42 CFR Part 2 allows for disclosure ~ where the state mandates child-abuse-and neglect reporting ~ when cause of death is being reported ~ with the existence of a valid court order Documentation – Release of Information ~ A written consent form requires ten elements (42 C.F.R. § 2.31(a); 45 C.F.R. § 164.508(c)): ~ 1. the names of the programs making the disclosure ~ 2. the name of the individual or organization that will receive the disclosure ~ 3. the name of the patient who is the subject of the disclosure ~ 4. the specific purpose or need for the disclosure ~ 5. a description of how much and what kind of information will be disclosed ~ 6. a patient’s right to revoke the consent in writing and the exceptions ~ 7. the program’s ability to condition treatment, payment, enrollment, or eligibility of benefits on the patient agreeing to sign the consent ~ 8. the date or condition when the consent expires if not previously revoked ~ 9. the signature of the patient (and/or other authorized person) ~ 10. the date on which the consent is assigned ~ When used in the criminal-justice setting, expiration of the consent may be conditioned upon the completion of, or termination from, a program Documentation – Information Sharing ~ Information can be shared within an agency on a need to know basis with person on the treatment team ~ Information sharing can be done ~ With a release ~ To the client ~ Under specific circumstances ~ Agencies generally have policies for who is allowed to release information ~ Clients have the right to review and amend their records ~ If request to view or amend the record is denied, a written explanation must be provided to the client HIPAA and HITECH Act ~ Protects insurance coverage of workers when they change or lose their job ~ Safeguards the privacy of information ~ Combats waste in healthcare delivery ~ Simplifies administration
