Patient Health Record Documentation Policy

Policy: Patient Health Record Documentation

Policy Number: 304 Policy Section: Quality
Owner: Cynthia Grant Approved By: Paul Vogelman, COO
Effective Date: 5/23/2022 Date of Last Review: 3/23/2023


SUD Specialty Group -- CA; Mental Health Specialty Group, P.A.; Mental Health Specialty Group NJ, PC; and Mental Health Specialty Group KS, P.A. (collectively, the "Group") contracts with Path CCM, Inc. d/b/a Rula Health ("Rula") for management and administrative support services. This policy applies to the Group and Rula.


Policy Statement

This policy ensures proper documentation of services provided to patients. Proper health record documentation supports treatment and continuity of care, but also supports billing and reimbursement, provides data for outcomes, ensures compliance with state level and payor requirements, provides evidence of the quality of patient care, and serves as a resource for provider education.



This policy applies to Group team members as well as Rula, CCM team members who are responsible for documenting and/or making entries in patient’s health records. For purposes of this policy, the Group and Rula team members include individuals who would be considered part of the workforce such as employees, independent contractors, business team members, and other persons whose work performance is under the direct purview of Rula’s business practices. 



Author: any person entering information into the patient’s health record



  1. Patient Health Record Content
    1. Any information produced as a result of an assessment and/or treatment of a patient (whether in person, by telephone, or by electronic means) must be made part of the patient’s health record. The exact content of the record will depend on the nature of the services provided to the patient and any state or payor specific requirements. This policy provides a brief summary of the basic medical record content requirements. Other policies or clinical quality practice guidelines may provide additional specific content required. 
    2. Each provider is responsible for maintaining records and reports in such a manner to ensure accuracy and easy retrieval. 
      1. Each patient who receives any treatment service must have a patient health record established in the Electronic Health Record (EHR) that contains sufficient information to clearly identify the patient (patient ID), document the diagnosis, care, treatment, and results accurately. 
      2. Patient health records must contain the information as required in the Designated Record Set policy. 
      3. All documentation must be professional and written with the expectation that patients and/or outside agencies will view these documents - including documentation in the record that is not associated with a “billable” service. 
      4. Documentation must be individualized to the patient and specific to the service provided. 
      5. Patient health records entries will be complete, dated, legible, will include credentials, and will be authenticated by electronic signature of the author making the entry. 
    3. Each billable patient service should include: 
      1. Reason for the service (why it is medically necessary)
      2. Observations and assessment of the patient, including progress in treatment, type of intervention provided, and patient’s response to the intervention 
      3. Plan for next session or overall care
      4. Date and legible identity and credentials (where applicable) of the person providing the service.
  2. Users and Access
    1. Only authorized individuals shall make entries into a patient’s health record. 
    2. Authorized users of the EHR shall enter information only under their own usernames/passwords. Sharing of logins is prohibited under the HIPAA Security Rule and may result in disciplinary action. Entering information under another user’s login is prohibited and may result in disciplinary action. 
    3. Each author is responsible for the completeness, accuracy, and truthfulness of the information entered into the EHR under their login.
    4. Each author writing a note in the EHR is responsible for the overall content and timely signing/finalizing of the note. 
    5. For more information regarding authorized users and access to the EHR, refer to the Access Control Policy.
  1. Timeliness of Entries in the Health Record
    1. Services should be documented during the service or as soon as practical after the service is provided, but no later than 24 hours after the service occurs. 
    2. Entries shall never be made in advance of a service.
    3. Charge slips for billable services are to be completed after completion of the appropriate documentation note for the service. 
    4. Claims for services will not be submitted until the documentation for the service is finalized. 
  2. Addendums
    1. Authors may edit documentation while a note is in draft/saved form.  
    2. Once a note is signed by the author, any edits or additions must be made using an addendum. 
    3. An addendum to the record is used to correct an entry after the original document has been signed and finalized. 
    4. Addendums will be:
      1. Written using a Blank Note template;
      2. Clearly identified as an amendment, correction, delayed entry;
      3. Be completed as soon as possible after the need for an amendment, correction, delayed entry is identified;
      4. Clearly indicate the date, time, and author of the amendment;
      5. Clearly refer to the date and service provided for which the amended, delayed or corrected entry is written. 
      6. Identify any sources of information to support the amendment, delay, or correction.
  3. Shortcuts and Jargon
    1. Copying and pasting information from the documentation of a past service into the documentation for a current service is prohibited. 
    2. Copying and pasting information from one patient’s health record into another patient’s health record is prohibited. 
    3. Jargon, shorthand/abbreviations, and acronyms should be avoided in the patient’s health record. 
      1. Acronyms may be used when accompanied by an explanation upon the first use of the acronym. For example: A provider may document that a patient is “working on their ADLS (Activities of Daily Living Skills)” then further in the note the provider may write, “patient will continue to work on ADLS as evidenced by…” 
      2. The explanation of the acronym only has to be used the first time in each service note documentation. 

Attachments: None

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