A Primer on Medical Records
Q. What standard must a psychiatric record satisfy?
A. There is no simple answer to that question, as requirements vary from state to state and from practice setting to practice setting. The following list presents the suggested major “contents” of a psychiatric record. (Please remember that federal and state laws and regulations may impose additional requirements.)
These are the types of information that should be included in patient records:
• Initial assessment, diagnosis, and subsequent reassessments of the patient’s clinical status.
• Initial and ongoing assessment of suicide risk, as appropriate.
• Patient history and examination.
• Treatment recommendations/plan and modifications.
• Documentation of the informed-consent process and signed informed-consent forms.
• Medication information (the medication name, the dosage and size of the prescription, the number of refills, the effectiveness of the medication, any reported side effects, any medication allergies/sensitivities, any changes of medication or dosage, the basis for such modifications, and so on).
• Instructions communicated to the patient and/or family.
• The dates (and length) of services.
• Authorizations for release of information, including releases to third-party payers.
• The names, addresses, and telephone numbers of the patient and designated others, if the patient has granted appropriate authorization to communicate with others.
• Consultations with other health care providers.
• Reports from psychological testing, other examinations, laboratory data, and so on.
• What treatment options/actions were considered, what options/actions were chosen and why, and what treatment options were rejected and why.
• Progress notes and/or other documentation that reflects the patient’s reaction to treatment or the need to change treatment.
• Documentation of the termination or transfer of treatment process.
• A discharge summary (if relevant), including the patient’s status relative to treatment goals.
• Copies of relevant correspondence concerning the patient.
It is good practice to establish separate sections within a record for clinical documentation, patient billing information, correspondence regarding the patient, and records from other health care providers or institutions. Communications with personal counsel or a risk manager should be kept separately in an administrative file.
Regardless of what specific elements should be included in a record, the primary underlying philosophy of documentation is that good documentation supports quality patient care and is the primary means of demonstrating that you practiced responsible medicine during the course of treatment.
Q. How do I obtain coverage through the Psychiatrists’ Program, the APA-endorsed Psychiatrists’ Professional Liability Insurance Program? When should I begin the application process?
A. Call (800) 245-3333, ext. 389, or e-mail [email protected] to request your individualized premium quotation. You can also download an application at www.psychprogram.com.
To prevent any gaps in coverage, please contact us at least one month before you will need coverage. This will allow sufficient time for the underwriting process and your submission of the necessary documents as identified in the application. You must be an APA member in good standing, and if you are not an APA member, you must have submitted your application for membership to APA before your insurance coverage can be finalized.
Q. What types of policies does the Psychiatrists’ Program offer?
A. The Psychiatrists’ Program offers occurrence, claims-made, modified occurrence, or claims-made with an extended claim-reporting endorsement (tail). (Not each type of policy is available in every state.)
An occurrence policy responds to claims resulting from incidents that occur during the policy period, regardless of when the actual claim is made. Coverage need not be in force at the time the claim is reported. It is only necessary that coverage was in force at the time the alleged negligence occurred.
A claims-made policy responds to claims that are filed during the policy period arising from treatment provided after the retroactive date of the claims-made policy. As long as the claims-made policy is renewed, coverage will apply. If the policy is canceled, an extended claim-reporting endorsement (tail) may need to be purchased. An extended claim-reporting endorsement is provided at no additional cost to members whose coverage is canceled as a result of death or permanent disability. At retirement, a reporting endorsement is also provided at no additional cost when a member reaches age 55 and has maintained a claims-made policy for at least five years immediately preceding retirement. An extended claim-reporting endorsement is also provided at no additional cost to any insured who has had 10 continuous years of claims-made coverage with the Program (subject to underwriting guidelines).
A modified occurrence or claims-made with prepaid reporting endorsement combines the best features of both occurrence and claims-made coverages. Coverage is provided for the services rendered during the policy period. The cost of the extended claim-reporting endorsement is included in the premium paid each year the policy is in force.
To learn more about insurance policies and related information, visit the PRMS Online Education Center at www.psychprogram.com for a complimentary multimedia tutorial.
This column is provided by PRMS, manager of the Psychiatrists’ Program, for the benefit of members. More information is available by visiting the Program’s Web site at www.psychprogram.com; calling (800) 245-3333, ext. 389; or sending an e-mail to [email protected]. You can also send your questions to this e-mail address. ▪
