Provider Enrollment and Ongoing Responsibilities : Documentation

Medical Records

A dated clinician's signature must be included in all medical notes. According to Wis. Admin. Code § DHS 106.02(9)(b), a provider is required to include certain written documentation in a member's medical record.

Medical records kept electronically are subject to the same requirements as those maintained on paper. In addition, the following requirements apply:

• Providers are required to have a paper or electronic back-up system for electronic medical records.
• Mental health and substance abuse service providers are required to have safeguards to prevent unauthorized access to the records (refer to Confidentiality and Proper Disposal of Records for more information).

Mental Health and Substance Abuse Services Documentation Requirements

Providers are responsible for meeting ForwardHealth's medical and financial documentation requirements. Refer to Wis. Admin. Code § DHS 106.02(9)(a) for preparation and maintenance documentation requirements and § DHS 106.02(9)(c) for financial record documentation requirements. The documentation must accurately reflect the services rendered and support the level of service submitted on the claim.

The following are the medical record documentation requirements (Wis. Admin. Code § DHS 106.02[9][b]) as they apply to all mental health and substance abuse services. In each element, the applicable administrative code language is in parentheses. Providers are required to maintain the following written documentation in the member's medical record, as applicable:

1. Date, department or office of the provider (as applicable), and provider name and profession
2. Presenting problem (chief medical complaint or purpose of the service or services)
3. Assessments (clinical findings, studies ordered, or diagnosis or medical impression)
   1. Intake note signed by the therapist (clinical findings)
   2. Information about past treatment, such as where it occurred, for how long, and by whom (clinical findings)
   3. Mental status exam, including mood and affect, thought processes — principally orientation X3, dangerousness to others and self, and behavioral and motor observations. Other information that may be essential depending on presenting symptoms includes thought processes other than orientation X3, attitude, judgment, memory, speech, thought content, perception, intellectual functioning, and general appearance (clinical findings and/or diagnosis or medical impression)
   4. Biopsychosocial history, which may include, depending on the situation, educational or vocational history, developmental history, medical history, significant past events, religious history, substance abuse history, past mental health treatment, criminal and legal history, significant past relationships and prominent influences, behavioral history, financial history, and overall life adjustment (clinical findings)
   5. Psychological, neuropsychological, functional, cognitive, behavioral, and/or developmental testing as indicated (studies ordered)
   6. Current status, including mental status, current living arrangements and social relationships, support system, current ADL, current prescribed medications, current and recent substance abuse usage, current personal strengths, current vocational and educational status, and current religious attendance (clinical findings)
   7. Substance abuse assessments are required to include documentation of nationally approved screening assessment to assure the appropriate level of care (e.g., the ASAM placement criteria)
4. Treatment plans, including treatment goals that are expressed in functional terms that provide measurable indices of performance, planned intervention, mechanics of intervention (frequency, duration, responsible party[ies]) (disposition, recommendations, and instructions given to the member, including any prescriptions and plans of care or treatment provided)
5. Progress notes (therapies or other treatments administered) must provide data relative to accomplishment of the treatment goals in measurable terms. Progress notes must also document significant events that are related to the person's treatment plan and assessments and that contribute to an overall understanding of the person's ongoing level and quality of functioning

Adult Mental Health Day Treatment Services Documentation Requirements

Providers are required to maintain a copy of the functional assessment scale in each member's medical record.

Providers are reminded to adequately document the purpose of groups as a part of day treatment, the member's needs as they relate to the group, and either the specific goals the member is attempting to meet by taking part in the group or the member's response to group intervention.