Electronic Medical Records (EMR) and Individualization of Documentation 1
Individualization of treatment and beneficiary-specific documentation in beneficiary records is required under Arkansas Medicaid regulations. 2
204.100 Inpatient The provider must develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity or session for which Medicaid reimbursement is sought. This documentation, at a minimum, must consist of: A. The specific services provided, B. The date and actual time the services were provided (Time frames may not overlap between services. All services must be outside the time frame of other services), C. Name and title of the person who provided the services, D. The setting in which the services were provided, E. The relationship of the services to the treatment regimen described in the plan of care and F. Updates describing the patient s progress. Documentation must be legible and concise. The name and title of the person providing the service must reflect the appropriate professional level. 3
Outpatient 218.000 Master Treatment Plan For each beneficiary entering the RSPMI Program, the treatment team must develop an individualized master treatment plan. 226.200 Documentation The RSPMI provider must develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity or session for which Medicaid reimbursement is sought. This documentation, at a minimum, must consist of: A. Must be individualized to the beneficiary and specific to the services provided, duplicated notes are not allowed. 4
5 Outpatient Procedure Codes 252.110 Outpatient Procedure Codes SERVICE: Master Treatment Plan (90885 HA, U2) DEFINITION: A developed plan in cooperation with the beneficiary (parent or guardian if the beneficiary is under 18), to deliver specific mental health services to the beneficiary to restore, improve or stabilize the beneficiary's mental health condition. The plan must be based on individualized service needs identified in the completed Mental Health Diagnostic Evaluation. SERVICE: Periodic Review of Master Treatment Plan (90885 HA) DEFINITION: The periodic review and revision of the master treatment plan, in cooperation with the beneficiary, to determine the beneficiary's progress or lack of progress toward the master treatment plan goals and objectives; the efficacy of the services provided; and continued medical necessity of services... DOCUMENTATION REQUIREMENTS... Completed by the primary MHP (If not, then must have a rationale for another MHP completing the documentation and only with input from the primary MHP)... Individualized rationale to support the medical necessity of continued services SERVICE: Pharmacologic Management by Physician (formerly Medication Maintenance by a physician) (90862 HA) DEFINITION: Provision of service tailored to reduce, stabilize or eliminate psychiatric symptoms by addressing individual goals in the master treatment plan.
Individualization of treatment and beneficiary-specific documentation in beneficiary records is required by the Arkansas Department Of Behavioral Health Services. 6
Individualizing Progress Notes See DBHS RSPMI Policy VIII, L (page 16) L. Providers must tailor all RSPMI care and services to individual client need. If client records contain entries that are materially identical, DBHS and the Division of Medical Services will rebuttably presume that this requirement is not met. 7
Advantageous Features of Electronic Medical Record (EMR) Documentation Availability of menus and drop-downs with common, useful choices Eliminate the need for repetitive data input via auto-population Streamline some aspects of authorship 8
Limitations of EMR Menu Choice Functions Do not supplant the need for authorship in certain required components of progress notes Not feasible to provide users with a sufficient number of options to adequately individualize treatment plans and progress notes 9
Elements of Progress Notes Requiring Authorship (RSPMI Manual Section II 226.200; 252.100 Inpatient Manual Section II 218.000; 226.200) Description of the service or treatment provided Beneficiary s response to the service or treatment provided Plan for the next service or treatment 10
Description of the Service or Treatment Provided [Example EMR Menu Choices -- Narrative = Incomplete Picture] Active listening Assistance with practicing coping skills Cognitive restructuring Confrontation and discussion Debriefing Development of strategies for symptom management Exploration of perceptions Practice of strategies for symptom management Problem solving Role play exercises Relaxation techniques 11
Description of the Service or Treatment Provided [Example EMR Menu Choices + Narrative = Complete Picture] Active listening Assistance with practicing coping skills Cognitive restructuring Confrontation and discussion Debriefing Development of strategies for symptom management Exploration of perceptions Practice of strategies for symptom management Problem solving Role play exercises Relaxation techniques Worked with Hubert on his symptom of distractibility by listening to him express his anxiety about being around noise, lights, and people in the grocery store. Challenged him to make a commitment to practice the deep-breathing and positive self-talk strategies we had been practicing before he goes to the store. 12
Beneficiary s Response to Service or Treatment Provided [Example EMR Menu Choices -- Narrative = Incomplete Picture] Actively participated Distracted Good Guarded No improvement Poor Perfunctory Required extensive prompting Some improvement Uncooperative Withdrawn 13
Beneficiary s Response to Service or Treatment Provided [Example EMR Menu Choices + Narrative = Complete Picture] Actively participated Distracted Good Guarded No improvement Poor Perfunctory Required extensive prompting Some improvement Uncooperative Withdrawn Hubert refused to make a commitment, saying he was sick of people not understanding his problem. He said if I really cared for him, I would go to the store and pick up the things he needed. I pointed out to him that attempts to manipulate others are not near as effective as using the deep-breathing and positive self-talk strategies he had learned. He snorted and said he was going to report me to my supervisor. 14
Plan for Next Service or Treatment [Example EMR Menu Choices -- Narrative = Incomplete Picture] Begin working on next objective Continue working on stated goal Discharge from specified service modality Make addendum to treatment plan Make referral to physician Make referral to therapist Meet with beneficiary for next scheduled appointment Meet with Collateral source for more information Report results in staffing Schedule follow-up appointment 15
Plan for Next Service or Treatment [Example EMR Menu Choices + Narrative = Complete Picture] Begin working on next objective Continue working on stated goal Discharge from specified service modality Make addendum to treatment plan Make referral to physician Make referral to therapist Meet with beneficiary for next scheduled appointment Meet with Collateral source for more information Report results in staffing Schedule follow-up appointment Check with Rehab Day staff to ascertain that Hubert continues to participate in relaxation and deep-breathing classes. Structure next Intervention service to focus only on one-on-one practice of relaxation/deep-breathing strategies. 16
Combined EMR Menu Choices and Narrative A Complete Picture! Service Description Active Listening Debriefing Exploration of perceptions Beneficiary Response No Improvement Poor Uncooperative Plan for Next Service Continue working on goal Report results in staffing Worked with Hubert on his symptom of distractibility by listening to him express his anxiety about being around noise, lights, and people in the grocery store. Challenged him to make a commitment to practice the deep-breathing and positive self-talk strategies we had been practicing before he goes to the store. He refused to make a commitment, saying he was sick of people not understanding his problem. He said if I really cared for him, I would go to the store and pick up the things he needed. I pointed out to him that attempts to manipulate others are not near as effective as using the deep-breathing and positive self-talk strategies he had learned. He snorted and said he was going to report me to my supervisor. Check with Rehab Day staff to ascertain that Hubert continues to participate in relaxation and deepbreathing classes. Structure next Intervention service to focus only on one-on-one practice of relaxation/deep-breathing strategies. 17
Individualizing Treatment Plans Treatment Plans for individuals of the same age and same diagnosis are often very similar; HOWEVER Symptoms vary in frequency and intensity among individuals with the same diagnosis Symptoms are expressed differently among individuals THEREFORE Person-specific objectives usually need to be added to standardized treatment goals and objectives in order to sufficiently address the needs of the individual. 18
Most EMR programming and software address the need for person-specific goals and objectives by: providing an other option for goals providing an other option for objectives. 19
Electronic Medical Records are justifiably credited for time-saving ease in many aspects of beneficiary record documentation; 20 HOWEVER The nature of behavioral health treatment and symptomology requires person-specific individualization; SO EMR + person-specific goals, objectives, and narrative = The Winning Combination!
21 Questions?