Name of Manual - Blue Cross and Blue Shield of Minnesota

Quality Improvement
Treatment Record
Documentation
(continued)
Treatment Plan
• The treatment plan must be comprehensive, current, and
consistent with the diagnosis. The formal treatment plan must
be completed within the first three visits.
• The treatment plan must contain clear, objective, and
measurable goals as well as the estimated timeframes for goal
attainment or problem resolution. Interventions must be
appropriate for the diagnosis and/or presenting problem(s).
• The patient must participate in the development of the
treatment plan and should sign the initial plan and sign or
initial all updates or revisions.
Progress Notes
• All entries must contain the date, actual face-to-face contact
time, and current diagnosis.
• All entries must document the persons present during the visit
without using the names of persons other than the identified
patient.
• The interventions must be consistent with the diagnosis and
correspond with current treatment goals.
• Recommendations or referrals for preventive or other external
services, e.g., stress management, relapse prevention, or
community services, must be documented.
• The documentation of each entry must clearly state the chief
complaint and current status of symptoms as well as patient
strengths and limitations in reaching treatment goals.
• There must be a notation in each entry about need for followup
care, plans for a return visit, or termination of treatment.
The specific date or timeframe of a return visit must be noted.
• There must be documentation of patient cancellation or failure
to show for a visit.
• Evidence of coordination of care with other relevant behavioral
health providers and/or medical professionals must be
documented.
• Unresolved problems from previous visits must be addressed
and the outcomes documented.
• If safety or risk characteristics are identified, they must be
prominently documented and addressed during each visit.
• Phone conversations with persons relevant to treatment, e.g.,
referral sources, physicians, or parents, must be documented.
3-26 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)