Name of Manual - Blue Cross and Blue Shield of Minnesota

Quality Improvement
Treatment Record
Documentation
(continued)
• There must be a signed patient authorization for all external
persons with whom treatment information is exchanged. No
treatment information can be exchanged without patient
authorization or court order.
• Each page in the record must contain the patient’s name or
identifying number.
• All entries must be dated and contain the author’s name,
professional degree/designation, and relevant identification
number if applicable. If a non-degreed professional completes
the entry, the title of the author must accompany the signature,
e.g., Family Skills Worker. Author identification may be a
handwritten signature or unique electronic identifier. Initials
alone are not an acceptable form of identification. Initials may
be used in conjunction with a typed signature block that clearly
identifies the author.
• Errors in documentation must be corrected with a single line
drawn through the error with the author’s initials.
Initial Assessment
• Presenting problem(s), as well as relevant psychological or
social conditions affecting the patient's medical or psychiatric
status, must be documented.
• Presenting symptoms that are consistent with DSM-IV-TR
criteria must be clearly identified and documented, including
the onset, duration, and intensity of symptoms as well as
functional impairment.
• A psychiatric history must be documented. The psychiatric
history should include, if applicable, previous treatment dates,
identification of former treating practitioner(s), therapeutic
interventions and responses, relevant family psychiatric
history, lab test results, and consultation reports.
• A medical history must be documented which includes current
and/or past major or chronic medical conditions and a current
list of medications. Medication allergies and adverse reactions
must be prominently noted. If the patient has no known
allergies or history of adverse reactions, this must be noted.
• For children and adolescents through age 17, a comprehensive
developmental history must be documented that includes
prenatal and perinatal events, achievement of developmental
milestones, and psychological, social, intellectual, and
academic history.
3-24 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)