Name of Manual - Blue Cross and Blue Shield of Minnesota

Quality Improvement
Treatment Record
Documentation
Rationale:
The patient behavioral health treatment record is a vehicle for
documenting services and evaluating continuity and coordination
of care. It also serves as legal protection for the patient and
practitioner. Blue Cross, per contractual agreement with both the
subscriber and provider, has access to the member’s record for
examination and evaluation. Blue Cross’ corporate confidentiality
policy requires that the personal and health information of its
members be maintained as confidential information. All employees
are required to attest to their knowledge of this policy and their
intent to comply with it.
Treatment record review is an essential component of a
comprehensive Quality Improvement program. The Blue Cross
Quality Council establishes minimum record documentation
standards.
Annually, Blue Cross audits a random sample of patient records
from the Blue Cross population. The records are reviewed in
accordance with the required documentation elements. If potential
deficiencies are identified at a given site, a more intensive review
may occur.
Requirements for Treatment Record Format and Content
Record Organization
• The format of the treatment record must be logical and
organized.
• All forms used in the treatment process must be standardized
and consistent for all records.
• The treatment record must contain the patient’s current
address, employer or school, home and work phone numbers,
marital or legal status, appropriate consent forms, and
guardianship status information.
• Special status situations, such as imminent risk of harm,
suicidal or homicidal ideation, or elopement potential, must
be prominently documented and updated.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-23