PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

1. History and Physical Examination. Appropriate subjective and objective information is obtained for the
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presenting complaints.
2. For members receiving behavioral health treatment, documentation to include “at risk” factors (danger to
self/others, ability to care for self, affect, perceptual disorders, cognitive functioning, and significant social
history).
3. Admission or initial assessment includes current support systems or lack of support systems.
4. For members receiving behavioral health treatment, an assessment is done with each visit about client
status/symptoms to treatment process. Documentation can indicate initial symptoms of behavioral health
condition as reduced, increased, or unchanged during treatment period.
5. Plan of treatment, which includes activities/therapies and goals to be carried out.
6. Diagnostic Tests.
7. Therapies and Other Prescribed Regimens. For members who receive behavioral health treatment,
documentation shall include evidence of family involvement, as applicable, and include evidence that family
was included in therapy sessions, when appropriate.
8. Follow-up. Encounter forms or notes have a notation, when indicated, concerning follow-up care, call or
visit. Specific time to return is noted in weeks, months, or PRN. Unresolved problems from previous visits
are addressed in subsequent visits.
9. Referrals and Results thereof; and
10. All other aspects of patient care, including ancillary services.
Medical Record Confidentiality
• If a properly executed written consent form does not accompany the request, the request will be denied in
writing. The written denial will contain the reason for the denial and instructions on how to request the
information properly. A copy of the denial will be returned to the member.
• If the request for member information is accompanied by a properly executed request for release of
information, the Medical Director will send the information if it is available in the facility. If not, the
Medical Director will refer the request to the member’s Primary Care Provider for action. This information
will be addressed to the requesting official via First Class U.S. mail in a sealed envelope marked
CONFIDENTIAL. A copy of the letter accompanying the released information will be sent to the member
and the member’s Primary Care Provider.
• PCHP members can review or obtain their own health care information by sending a written signed request
to the PCHP Medical Director. The request must include the member’s name, date of birth, Parkland
KIDSfirst, Parkland CHIP Perinate or Parkland CHIP Perinate Newborn ID number, and Medicaid number.
A copy of the request will be forwarded to the member’s Primary Care Provider.
• PCHP will respond in writing, within five (5) business days of the date of receipt of the request, to written
request by the member who asks to review their health care information.
• If the member wishes to view the information and it is available within the PCHP facility, an appointment
will be made for them during regular business hours. The member will be advised to bring current picture