Compliance of records is a state standard of record keeping. As a Compliance Officer of records, I need to make sure that staff is following state mandated regulations for clients’ files, whether they are paper records or an electronic medical record (EMR). The state guidelines are for Outpatient Mental Health Clinics (OMHC). Of course there are state guidelines for medical offices and anywhere state funding is involved.The state is quite specific in their guidelines and they typically audit agencies on a random basis. There are specific things they are looking for in records. If this is not done, licensing privileges of the organization are at stake.
If you take on Medicaid clientele, there are also random audits to make sure state funding is appropriated judicially. If not, there are fines for paying back funds delivered if the OMHC withholds the quality of care expected. Many agencies across the United States have had hefty fines for not keeping up with the standard quality of record keeping and care. So it is important, if you work for an OMHC, you adhere to the guidelines set forth by the agency and Compliance Officer. Some Compliance Officers also oversee adherence to financial record keeping ensuring that monies collected are in adherence with standards and that there is no double billing, billing for services not rendered, etc.
In our agency this position is divided. I only deal with the EMR that our agency uses. Prior to the EMR there were no standards in place. It was just assumed everyone knew what was required. Having EMR has made the job easier, but there is the occasional pitfall-catching records prior to the EMR that have not been updated. Overall, the EMR has made the world of compliance easier.