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.
Each state has written standards and they are individualized by state. Some things are similar universally. There is what is called the longitudinal approach to record keep. Each assessment of a client must contain certain items. One sets the stage for the diagnosis among a host of things. From the assessment, you make your diagnosis (es). In the diagnosis, you must compile a rationale for the diagnosis driven from your assessment. Currently we are using the 5 Axis diagnoses as written in the DSM-IV-TR. (This will change somewhat when the DSM-5 takes effect.) From the assessment and diagnosis, you develop your treatment plan. They are all linked together.
Your diagnosis should be clearly stated in your treatment plan as part of the Problem area. The Problem area should also include how the diagnosis impacts on the client’s life. The Goal should be what we are trying to ameliorate. The Objective is written in a specific, objective, measurable, and obtainable terms. What is the client trying to increase or decrease in terms of specific behavioral outcomes? Most often these behaviors are identified as what is being seen in the home or community. The behaviors have to be specifically seen and they need to be tied to the assessment. For example, client will decrease temper tantrums from 5 times a day to 1 time a day. You may have to become very creative in your Objective writing. It also must be client driven. What does the client/parent want changed? This may help you create meaningful Objectives.
There is a new part of the treatment plan called Interventions. This is what the therapist will do to help the client reach their Goals and Objectives. The Interventions are what coping skills you will be teaching the client. It cannot be that you just will use DBT or CBT. You need to spell out what strategies you will be using: coping strategies-identifying triggers, doing a behavioral chain analysis, teach deep breathing exercises, complete a trauma narrative, teach stop, think, and then act, teach walking away and counting to 10, doing role plays to enhance social effectiveness, etc. There are numerous ways they can be written as long as they tie back to the Objective, which ties back to the Goal, which ties back to the Problem, which finally ties back to the Assessment.
The above is a longitudinal approach to treatment and what is being looked at by auditors across the United States. This is one way to be in compliance with state guidelines. Each state is a little different in terms of what they are looking for, but these are the basics. We did not go into Progress Notes as each state is different in what is required there. However, when you get a new case, you should be able to read the assessment, rationale for the diagnosis (es), the treatment plan, and two progress notes and know what to work on with your new client.