Every healthcare facility should have accurate and complete record documentation of its patients. This helps to foster the quality and continuity of care. It creates a means of communication between providers and the members about the health status of an individual. It can also serve in providing a quality treatment, planning, delivery, and preventive healthcare. This paper analyzes various documentation requirements for the substance abuse hospital, implications for noncompliance in the setting, and compares it to other healthcare settings.
Documents to be completed
The documents which various providers are responsible for completing include written reports, client data, progress notes, and discharge summaries. The first documentation record required is when admitting the client. Information collected at the admission will include the name, address, gender, and date of birth of the person being served. Contact information for the person being served, a family, or any legally authorized representative should also be noted down. The practitioner should also record the reasons for admission. To assist with treatment, any allergies or adverse drug reactions should be recorded. There should also be a record of progress notes and consultant reports noted down if available. The diagnosis established and the treatment regime undertaken should also be noted.
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Progress notes include a documentation of the various interventions undertaken, generalized assessment, documentation review, and individualized responses. Various treatment interventions that have been undertaken or implemented and the patient’s response to those interventions should be noted. The assessment should include a generalized view of the individual’s mood, behavior, and their interpersonal functioning. Any relevant lab work or relevant medical conditions should also be noted in the progress notes. In case of group sessions, the individualized response to the various sessions should be noted down. The detoxification program should also be included in the progress note.
The written report is a document that provides reason and support decisions for various endeavors undertaken for treatment. Such a report can include an explanation of various indicators such as maladjustment to new situations, inappropriate behavior, positive drug screens, detoxification procedure, and criminal activity.
Documentation standards
Various documentation standards to be followed involve the nature of documents. The documentation of various interventions should be done with an accurate and complete description. The general documentation should also avoid the use of words that are vague or language that is general. In case the substance abuse hospital includes a rehabilitation program, providers should indicate whether the program was undertaken for the short-term or long-term. The differentiation of both treatments should be indicated through the type and scheduling of the treatment (Documentation Requirements - Substance use Treatment, 2018).
The billing of the services in the Substance Abuse Hospital should also be in line with the progress reports. Treatment programs are usually expected to provide a substantive behavioral health intervention for each day billed and should include weekends and holidays. The documentation should show that meaningful treatment has been provided for each day of service that was billed. Maintaining such an accurate report is critical for carrying out compliance audits.
Responsibilities of different healthcare providers
Various healthcare providers that are involved in the recording of various documents include the board certified substance abuse counselor, the licensed physician, registered nurse, and masters-prepared social worker. The counselor should be able to note the behavioral progress of the client. He or she should also write the written report detailing the entire treatment program. The licensed physician should record the diagnosis made and the treatment regime. The registered nurse should be in charge of compiling the progress notes accurately. The work of the social worker should also be to note the behavioral changes in various sessions such as group therapy.
Implications for noncompliance
Substance abuse hospitals undergo documentation audits to ensure compliance with various documentation standards. Noncompliance with the standard documentation requirements will lead to the entire treatment plan being labeled as “insufficient.” In case noncompliance is undertaken by the healthcare practitioner, they may face various penalties. It can also be treated as malpractice in case poor documentation leads to various complications. In case the entire facility is to blame, it may face several fines depending on the severity of the noncompliance.
Comparison to other settings
Documentation standards in the substance abuse hospital are similar to that in other healthcare settings. For the acute care, hospital emphasis is given on the medical record should entail the record of the patient both as an in-patient and later as an outpatient. Various documentation records include admission and consent records, history and physical records, nurses’ notes, physician’s progress notes, and consultation records. The mental health clinic places an emphasis on documents that show history and current status of the client’s mental, behavioral, and emotional health. Documentation assessments should be provided to support the medications undertaken in the mental health services (MSI, 2013). Rehabilitation facilities should ensure that their documentation justifies the services rendered and the severity of the patient. The preadmission screening is an important document that should be performed by a licensed physician, it should record the specific care that should be required.
In conclusion, adherence to documentation standards is important for both the patient and healthcare practitioners. The main function of documentation is to record the interventions, challenges, and progress made during treatment. It allows the healthcare practitioners, the individual being treated, and the subsequent staff to review effective treatment strategies. A clear and concise documentation is also critical for substantiating payments made by the patient (Campanella, 2015).
References
Campanella, P., Lovato, E., Marone, C., Fallacara, L., Mancuso, A., Ricciardi, W., & Specchia, M. L. (2015). The impact of electronic health records on healthcare quality: a systematic review and meta-analysis. The European Journal of Public Health , 26 (1), 60-64. Retrieved from https://academic.oup.com/eurpub/article/26/1/60/2467302 .
Documentation Requirements- Substance use Treatment, (2018) Retrieved from https://dbhids.org/wp-content/uploads/2018/05/Bulletin-18-05-Per-Diem-DA-Doc-Reqs-2.pdf
MSI, M. S. I. (2013). Retrieved from Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/sites/default/files/grants/pdf/sp-14-005_0.pdf
