Client Records Department: Supporting Compliant Record Documentation

1. Client Records March, 2009

2. Meet your Client Records’ Staff My name is Melissa, I represent providers with last name beginning with A ending with F A - F April Wade Client Record’s Department Manager My name is Dylan, I represent providers with last name beginning with G ending with P G - P My name is Karen, I represent providers with last name beginning with Q ending with Z Q - Z

3. Department Focus • Provide the guidance and instructions necessary to ensure compliant record documentation • Complete quantitative reviews to verify documentations compliancy • Provide affiliate providers with paperwork trainings • Process consents to release/obtain documentation • Records management • Discharge clients

4. Quantitative Review • Record Reviews are complete to prepare us for MH Licensing reviews, COA and billing audits What we look for during a record review: • Clients LEGAL name and Identification Number on every page.(if 2 sided document - both sides) • Billing Tickets and Progress Notes must match to successfully post a bill: Every entry in the record MUST have: - A date of service - Time spent - Progress Toward Goals/ Objectives

5. CanYOurEad thiS? All documentation must be: • Clear, concise, legible • Signature with credentials of the person writing the note (must include the printed name of person making the notation.) • Documentation that’s not legible, is not billable for services. * If you can’t read it, then the service didn’t happen!!!

6. Also… No document should have blank areas on it - example: unmet needs or barriers should never be left blank. Documents should be typed, or if handwritten, legible and in black or blue ink. White-Out, Correction Tape, Pencil, Red Ink, etc. should NEVER be used. Verify that the client’s name, ID# and DOB are match

7. Releasing/Obtain Client Information • A release is needed if the clinician intends to share information with other professionals, as authorized by the client. • Who processes consents? Client Records Department • Why?Affiliates fall under Sweetser as a covered entity and therefore Affiliates are to comply with the written policies/procedures that Sweetser developed to cover the HIPAA privacy rules. •  What to do when a Release of Information is received?Fax to Client Records and contact your Client Records Specialist. • Benefits:Saves the Provider time, ensures “minimum necessary” rule is met. Sweetser has trained staff to be sure that the release is compliant. All processed releases are logged into a disclosure log. • If we receive a release that has not come directly from you, you will receive a courtesy email from your client records specialist notifying you of the release.

8. Discharge Process When you and your client have determined that a successful course of treatment has occurred, a discharge summary form needs to be completed and signed by the clinician. Fax the discharge summary to 284-6366, a Sweetser Client Records Specialist will process the discharge.

9. The Client Records Department is committed to Sweetser’s Affiliate Network! Our goal is to answer all your questions, respond to your e-mails, voicemails, and any other request in a timely fashion, while providing you with good quality customer service.

10. Any Questions? Contact a client records support staff ! 