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are available in our Provider
Library.
Behavioral Health Providers and Networks
Regence Behavioral Health
Treatment Plan Request Form
Should you have any questions about the changes to
behavioral health administration or benefits, please
contact one of the behavioral health provider relations
representatives listed below:
Clinical documentation
of therapy sessions
General guidelines
Clinical notes for outpatient and inpatient therapy
sessions serve to document not only the patient’s
clinical status and progress, but also serve to ensure
that quality of care is adequate and payment is made
for services provided. Clinical notes do not need
to be lengthy. At the minimum, clinical notes should
include:
- date and length of the therapy sessions
- patient's current clinical status as it relates
to diagnosis and as evidenced by the mental status
observations
- content of the therapy session, i.e., note of the
major themes discussed
- summary of the therapeutic intervention of the
session,
- summary of your assessment of the patient's progress
or lack of progress toward the treatment goals
- treatment plan for the immediate future, and
- medications being prescribed by the writer, such
as the name, dosage, instructions and any side effects
that have occurred. The record should document that
noted positive benefits outweigh noted side effects.
Group, Conjoint, and Family Therapy
Clinical notes are required for each group, conjoint
or family therapy session. Again, the notes need
not be lengthy. The clinical notes should include:
- date and length of the therapy session
- number of participants
- relationship of the participants to the patient
if it is conjoint or family therapy
- content of the therapy session (i.e., major themes
discussed)
- statement summarizing the therapeutic intervention
attempted during the therapy session
- statement summarizing how the session has influenced
the patient (or relevant significant others) as compared
with the treatment goals, and
- nature and degree of the patient's participation
and response to the therapy session
In long-term therapy, progress may be slow. The patient's
reactions to therapeutic interventions may not be observable
from session to session, but may evolve over several
sessions The record should include documentation that
each therapy session was an active, directed process
and that the therapist regularly took stock of specific
important treatment issues.
Inpatient Psychotherapy
Clinical notes for inpatient psychotherapy should contain
all of the elements noted previously in order to
adequately document that individual therapy was provided.
Therapeutic progress notes should occasionally include
reference to progress regarding the therapeutic plan
and the discharge plan, both of which should have
been established and documented during the early
part of the hospitalization.
These documentation requirements should serve to assist
in the maintenance of an adequate level of quality
of care as well as to help ensure that payment is made
only for services rendered.
Psychotherapy chart notes
and the HIPAA Privacy Regulation
The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) outlines five regulations which
will significantly change the manner in which health
care information is collected, transmitted and protected.
Once such regulation relating to privacy becomes effective
in April 2003. Since the Privacy Regulation pertains
to oral and written communication as well as electronic,
it affects most healthcare providers.
Under this regulation, providers will be required
to post detailed privacy policies in a conspicuous
place to advise patients of their rights, including
the right to request their personal medical record.
HIPAA access to medical records is much more permissive
than current Oregon Law, except with regard to psychotherapy
notes.
Mental health professionals are permitted to maintain
psychotherapy notes separately from the rest of the
chart. These psychotherapy notes may represent personal
notes used to record or analyze group, individual or
family therapy, and unlike the rest of the chart do
not have to be disclosed to the patient. However, under
the HIPAA Privacy Regulations, psychotherapy notes
are secured by a specific authorization, not by a general
consent.
Non-psychotherapy notes are maintained in the patient’s
chart, Any items falling into the non-psychotherapy
notes category must be disclosed to the health plan
and also to the patient, with only a general consent.
With patient authorization (specific disclosure with
expiration and/or revocation rights) psychotherapy
notes may also be disclosed to the health plan. All
Regence BCBSO and affiliated health plan agreements
require the creator of the record to release records
necessary to facilitate payment and health plan operations.
In the future, Regence BCBSO will require contracted
physicians and other mental health and chemical dependency
providers to secure authorizations under HIPAA that
permit them to "use and disclose" information
to the health plan. These authorizations will also
permit Regence BCBSO to use, but not re-disclose information.
If this information then required re-disclosure, additional
authorization from the patient will be sought by the
health plan.
By HIPAA definition, "non-psychotherapy notes"
include notes relating to:
- diagnosis
- functional status
- treatment plan
- progress notes
- medications
- prognosis
- symptoms
- treatment encounters, and
- clinical tests
One alternative for behavioral health providers is
to maintain notes for the patient and the health plan
in one part of the chart, and psychotherapy notes for
the professional provider as the "creator"
and the health plan in another part of the chart.
Under some circumstances non-psychotherapy notes may
be sufficient to meet health plan needs for documentation.
However, the quality of record keeping varies widely
and access to psychotherapy notes may be necessary
to make payment on some claims.
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