Treatment Record-Keeping Standards

University of Miami Behavioral Health (UMBH) is organizationally accountable for establishing and promulgating treatment record standards. UMBH requires treatment records to be maintained in a manner that is current, detailed, and organized which permits effective and confidential enrollee care and quality review.

UMBH has established treatment record documentation guidelines, standards for availability of treatment records, and performance goals to facilitate communication, coordination, and continuity of care within the behavioral health continuum, and among behavioral health clinicians, medical delivery systems, and primary care physicians.

The treatment record, whether electronic or on paper, communicates the enrollee’s clinical history; past and current health status; and treatment plans for future clinical care. Well-documented treatment records facilitate communication, coordination, and continuity of care as well as promote efficiency and effective treatment. Treatment records are the primary vehicle for the maintenance and communication of a patient’s personal health information. Consistent and complete treatment records are an essential component of quality patient care.

UMBH’s guidelines for treatment record documentation, standards for availability of treatment records, and performance goals define its expectations for practitioners. UMBH assesses treatment records to ensure that practitioners in its network comply with these guidelines and standards.

1. UMBH expects practitioners to maintain an organized treatment record-keeping system.
    
2. The following elements are required components of an organized record-keeping system:
    
   2.1. A unique treatment record for each patient.
   
   2.2. Treatment record notes maintained in chronological order.
   
   2.3. An organized system for maintaining documents for each patient. For example, all diagnostic reports maintained together in a section of a folder.
   
   2.4. An organized filing system that provides easy access to unique patient files. For example alphabetical filing or filing by unique patient identifier such as social security number.
    
3. Treatment records must be available as appropriate, to practitioners and staff other than the treating practitioner (for example, a covering practitioner).
   
   3.1. There is a practice site specific process for assuring treatment record availability whether the records are maintained centrally or in the treating practitioner’s office.
    
4. Treatment record documentation occurs as soon as possible after the encounter. Special status situations, such as imminent harm, suicidal ideation, or elopement potential, are prominently noted.
    
5. Practitioners must have a process for communicating information to the patient’s PCP and other health care practitioners within the behavioral health continuum and within the non-behavioral medical delivery system.
   
   5.1. The practitioner may use a specific form, a letter, verbal communication, or other appropriate process to communicate information to other caregivers.
   
   5.2. The content and date of the communication with other practitioners must be documented in the treatment record.
    
6. Treatment records must be maintained in a secure and locked location with limited access to ensure confidentiality.
    
7. Documentation is required of appropriate:
   
   7.1. Consent to release of information.
   
   7.2. Informed consent for services.
    
8. UMBH does not require use of specific forms for release of information and consent for services.
    
9. Treatment record maintenance requires that:
   
   9.1. Errors are corrected by drawing a line through the error and initialing it.
   
        9.1.1. Errors are always readable after correction.
   
   9.2. White out is never used in the treatment record.
   
   9.3. Entries are made only in ink.
   
   9.4. Abbreviations, if used, are standard or readily identifiable to others.