Full Clinical Guidelines - Community First Health Plans.

Criteria
Requirements
15. Support Systems Admission and initial assessments must include current support system or lack thereof.
16. Risk Factors Factors that may put the patient at risk must be documented; examples include current
abuse, current living situation, no family support, history of mental illness, danger to self
or others, perceptual disorders, etc.
17. Mental Status At each visit the patient’s current mental status is documented.
18. Diagnosis The diagnosis identified during each visit should be documented and should be consistent
with findings. ICD-9 code(s) may be used but must include the written description of the
diagnosis.
19. Treatment
Based on the chief complaint, exam findings and diagnosis, the treatment plan is clearly
Plan/Goals
documented.
20. Appropriate Use of If a patient problem occurs which is outside the physician’s scope of practice, there must
Consultants
21. Appropriate
Studies
Ordered
be a referral to an appropriate specialist.
The laboratory and other studies ordered should be consistent with the treatment plan as
related to the working diagnosis and should be documented at the time of the visit.
Abnormal findings must have an explicit notation of follow-up plans.
22. Review of Studies There must be evidence that the physician has reviewed the results of diagnostic studies.
Methods can vary, but often the physician will initial the lab report or mention it in the
progress notes.
23. Medication
Management (P)
24. Medication
Education (P)
25. Hospital/ER Records
(appropriate to
behavioral health)
26. Results of
Consultation/
Referrals
27. Teaching Regarding
BH Issues
28. Change in
Behaviors/Symptoms
29. Coordination with
PCP
30. If Child – Involvement
Of Family
31. Follow-up if missed
appointment
Documentation should reflect that the psychiatrist provides continuous evaluation of the
medication(s) prescribed to the patient as well as review of other medications prescribed
by the PCP or other specialist.
Documentation will include information about the effects of a prescribed medication to
include adverse effects. Information should include whether handouts on the medication
were given to the patient and/or parent/guardian.
Pertinent inpatient records must be maintained in the office medical record.
When the patient is referred to another physician/practitioner for consultation, there must
be a copy of the consult report and any associated diagnostic work up in the medical
record. The BH physician/practitioner’s review of the consultation must be documented.
Often the physician/practitioner initials the consult report.
The member is provided basic teaching/instructions regarding behavioral health
conditions.
At each subsequent visit, changes in the patient’s behavioral health symptoms/behaviors
are documented.
Evidence (at least quarterly, or more often if clinically indicated) that the patient’s PCP is
notified that his/her patient is receiving behavioral health services. This can be
demonstrated through use of the CFHP form or a summary report of the patient’s
status/progress from the Behavior Health provider to the PCP. A copy of the report
should be maintained in the record.
If the patient is a minor, involvement of his/her parent/guardian is documented. If the
minor is receiving services that allow for no involvement of the parent/guardian, this is
also documented.
If the patient misses a scheduled appointment, documentation will reflect that follow-up
contact was made. This can be done by letter or phone. If there is no response, this also
should be documented.
32. Date of Next Visit Encounter forms or notes should have a notation, when indicated, regarding follow-up
care, calls, or visits. Specific time of return should be noted in weeks, months, or as
needed.
(P) Required by Psychiatrists ONLY. (Not within scope of practice for other types of Behavioral Health Providers)
P: Quality Management\Medical Record Review\SFY2012\Documentation Guidelines Revised 1/10, 8/11
32 H EALTH PLANS
www.cfhp.com