Quality Management Information for Providers
Treatment Record Documentation Requirements
Consistent and thorough documentation in the treatment record is an essential component of quality patient care. Well-documented treatment records facilitate communication, coordination, and continuity of care. The efficiency and effectiveness of treatment is promoted by such documentation. As such, Quest has established treatment record documentation standards. The treatment record as the primary source of data about the patients also reflects the quality of behavioral healthcare provided to the patient by the clinician. Providers and facilities are expected to maintain clinical records for each member in accordance with the Quest treatment record documentation standards. The treatment record must be filed to ensure confidentiality and access limited. They must be retrievable to ensure availability to practitioners, office staff, and Quest, when needed. Quest may routinely conduct a treatment record documentation audit of participating practitioners who provide behavioral health services to Quest members. Feedback will be provided and, where deficiencies exist, improvement will be requested. Follow-up audits will be conducted and compared with prior results. NCQA may also request a review of records to make an independent judgment on the adequacy of Quest practitioner's treatment record documentation. Offices should be able to meet requirements for treatment record keeping and the maintenance of a consistent and flowing chart system.
