Mental Health Committee members raised several questions at the MH Committee meeting on July 16 regarding Medical Assistance Bulletin #29-02-03 Documentation and Medical Record Keeping Requirements. Specifically, the committee requested clarification on two requirements stated in the bulletin:
"The treatment plan must be included in the patient's record and the treatment objectives must state:
"2. The name(s) of the individual(s) who will be delivering the services;
"The documentation of treatment or progress notes, at a minimum, must include:
"4. The place where the services were rendered;"
The Office of Medical Assistance Programs (OMAP) representative clarified that for requirement number 2 regarding the name of the individual delivering the services; this can be documented through the signature on the progress note. However, the treatment plan should identify the types of service being rendered to the individual and the title of the staff that will be rendering the service, i.e., Therapist, CRNP if applicable, psychologist, psychiatrist, etc.
Requirement number 4 regarding the place where the services were rendered can be documented by including the address of the center where the services is located. More specific information such as room numbers is not required. The treatment or progress notes could include the facility name/address in the header or footer of the page. This would account for the treatment location. If treatment were to be provided in a different setting - an outing type situation, then that location information would need to be documented in the progress notes.
For more information, contact Rebecca May Cole at the Association.