II.M DOCUMENTATION OF CLINICAL CARE

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Mon, 06/26/2017
Revised: 
Thu, 04/13/2017
Policy: 
  1. All clinical interactions with patients are documented by CAPS professional staff with a signed, contemporaneous note in the medical record in accordance with professional standards and regulatory guidelines.
  2. Clinical documentation is accurate and completed in a timely manner.
  3. Clinical records are maintained in an electronic medical record with security features that preserve privacy but allow timely viewing by health care practitioners with appropriate permissions.
  4. Unlicensed staff and trainees require the co-signature of their supervisor for all clinical documentation.
  5. The electronic record provides the time and date when notes are electronically signed. Notes written on a subsequent date are dated with the actual date of signature, even if referring to an earlier interaction. 
     
Procedure: 

1. Crisis Notes:

  • Licensed Staff-Crisis services provided by licensed staff need to be documented within one working day.
  • Unlicensed Staff- Crisis services provided by unlicensed staff need to be documented within two working days, to allow time for review by licensed staff.
  • 5150 cases-If a student is involuntarily psychiatrically hospitalized from CAPS, documentation must be completed by the end of the day.

2. Non-Crisis Notes

  • Licensed Staff
    • Intakes must be completed within three working days of the service
    • Follow-up notes must be completed within two working days of the service
  • Unlicensed Staff- Review of the record and co-signature by supervisor for non-crisis services must occur within 5 working days of providing the service.

3. ADHD Assessments

  • Due to the time needed to complete, review, analyze, document, supervise, and co-sign the results of an ADHD assessment, staff have 10 working days from completion of testing to finalize documentation.

 

4. Content of clinical entries include, at minimum:

  • Date of service
  • Provider name and title
  • Chief complaint or nature of visit, with appropriate history
  • Objective clinical findings
  • Diagnosis, assessment or impression
  • Treatment plan documentation
  • A history of serious suicide attempt(s), dangerousness to others, or major alcohol/other drug (AOD) problem(s) are documented in the Clinical Comment section with the following codes, with reference to the date of a CAPS note that describes the problem:
    • History of serious suicide attempt(s) or dangerousness to others: “Hx (see x/x/xx note)
    • Major AOD problem(s): “Rx (see x/x/xx note)
  • Therapies administered or recommended with discussion of necessity, risks, and alternatives as appropriate

 5. Initial intake note will include:

  • Relevant history including- history of present illness, history of past psychiatric, medical and substance use problems, brief family history, academic/employment history
  • Mental status examination
  • Risk of harm to self or others
  • Known or potential addictive behaviors and substance abuse
  • Client self-understanding, motivation, and decision-making
  • Diagnosis, assessment, or diagnostic impression
  • Plan, including any medications prescribed.

6. A re-intake evaluation should be completed if it has been more than one year since the last visit. At the clinician’s discretion, a re-intake note may be added to the chart when a student sees a new provider, or if there has been a significant lapse of time or change of condition since the last visit.

7. Termination of services will occur under the following circumstances:

  • Mutual agreement between provider and student
  • Student referred for off-campus treatment
  • No further contact is received from the student after outreach

8. Termination will be documented in the student’s EHR and will include:

Dates of service, diagnosis or diagnostic impression, level of risk at last contact, treatment administered, number of sessions, change in symptoms, disposition, and any final revisions to the Clinical Comment entries made by CAPS.

A clinical record can be terminated when the treatment is completed or at the end of the academic year at the discretion of the clinician.  Cases are terminated when students leave the university, treatment is completed, treatment is transferred to a provider off-campus, or are no longer eligible for services through CAPS.

Written terminations are done for individual therapy.  For group, a summary can be provided in the last group documentation.   If only an intake was conducted, a case management note for termination is sufficient.

Formal terminations are not required for psychiatric services as they are open-ended and students often start and stop treatment.  Psychiatric staff can choose to complete a termination form.

9. Telephone contact with a patient is clearly identified as such in the medical record and content of the call is noted in the EHR, with appropriate clinician signature.

10. Documentation errors are corrected using addendums to the note unless the documentation was entered into the wrong patient's chart in which case follow the Medical Records Standards policy & procedure: XI. Corrections and Amendments to Records

11. Messages about clients to other CAPS staff are sent using the secure message system. The secure message system has more stringent security features than campus email.  Campus email is not used for protected health information.

12. Security of Mental Health Records - Health practitioners lock the computer screen prior to leaving the treatment room and screens automatically time out after 5 minutes if they inadvertently forget to lock the screen. Reminders to lock the screens are found on the work station. Paper protected health materials are collected throughout the day and locked up at the end of each day in the alarmed medical records office.

Key Points: 

 

  1. Documentation of clinical care occurs in the patient’s electronic health record.
  2. Documentation occurs in a timely manner, using standard clinical format.
  3. Documentation errors are corrected using addendums to the note unless the documentation was entered into the wrong patient's chart in which case the medical records administrator can clear a note from an EHR.
  4. Security features to assure the safety of protected health information include the lock-out features in the EHR and regular collection of paper materials for storage in the locked Records office.