Full Clinical Guidelines - Community First Health Plans.

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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
Criteria Requirements 33. Release of A signed release of information is obtained as indicated, which will permit specific Information information sharing between providers. 34. Care Coordination The medical record should reflect evidence that all professionals are included in primary and for Members with specialty care service team for CCSHCN members who may have co-occurring Behavioral Disabilities or Health disorders. Chronic/Complex Special Health Care Needs (CCSHCN) 35. Evaluation for abuse The medical record should reflect evidence that the provider evaluates for signs / symptoms or / neglect or other behaviors associated with abuse / neglect or other significant socioenvironmental factors. socioenvironmental factors 36. Diagnosis Validation The record should reflect that the billing diagnosis is consistent with that of the chief complaint. 37. Claims Validation The record should reflect the documented encounter is appropriate for the level of E/M services billed. (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 H EALTH PLANS www.cfhp.com 33
Page 1 and 2: Community First Health Plans Qualit
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Page 9 and 10: The purpose of these guidelines is
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Page 13 and 14: Recommended Adult Immunization Sche
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Page 45 and 46: GLYCEMIC CONTROL BIBLIOGRAPHY • R
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D i a b e t e s t r e a t m e n t a
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CFHP has adopted the National Insti
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No CHD; 0 to 1, or 2+ Risk Factors
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NATIONAL CHOLESTEROL EDUCATION PROG
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NATIONAL CHOLESTEROL EDUCATION PROG
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Identification, Evaluation, and Tre
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11.3 Treatment of Hypertension H EA
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ALGORITHM FOR TREATMENT OF MAJOR DE
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CFHP has established guidelines for
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A. Documentation ______ B. Continui
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CFHP PCP MEDICAL RECORD REVIEW TOOL
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13.3 Specialist Medical Record Docu
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13.4 Specialist Medical Record Revi
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Risk Factors for Osteoporosis Fract
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It is well documented that obesity
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CLASSIFICATION OF OVERWEIGHT AND OB
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16.1.1 Preventive Pediatric Health
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H EALTH PLANS www.cfhp.com 117
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TEXAS MEDICAID PROVIDER PROCEDURES
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CHILDREN’S SERVICES HANDBOOK P h
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CHILDREN’S SERVICES HANDBOOK P R
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H EALTH PLANS www.cfhp.com 139
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FIGURE 2: Recommended immunization
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Comprehensive antepartum care is vi
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The following variables should be e
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CRITERIA 19. Unresolved Problems Fr
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CFHP OB/GYN SPECIALTY MEDICAL RECOR
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CFHP OB/GYN SPECIALTY MEDICAL RECOR
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According to the National Institute
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. aminotransferase (AST) and alanin
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PREVENTION RECOMMENDATIONS 1. The E
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2 to 20 years: Boys Body mass index
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AsthmaMatters is an initiative deve
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According to the Centers for Diseas
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