Treatment Record Documentation Review

Corphealth has developed guidelines for treatment record documentation, standards for availability of treatment records and performance goals to define expectations for practitioners.  Corphealth assesses compliance with treatment record documentation standards annually.  Reviews are conducted in the practitioner’s office to allow for face-to-face contact and training.  The performance goal is 85%.  During record reviews, Corphealth will assess a random selection of treatment records to ensure that network practitioners comply with these guidelines and standards.  In addition, administrative management of records is also assessed.

The sample selection represents 50% of the high volume practitioners in each market where Corphealth has business.  High volume is defined as a practitioner who sees 10 or more enrollees three or more times in a 12 month period. 

Expectations for Treatment Records

The following are the Corphealth expectations for treatment record keeping practices: 

• Treatment records are maintained in a manner that is current, detailed and organized.

• Confidentiality of treatment records is maintained according to applicable state and federal regulations.

• Practitioner office staff is trained and experienced in handling confidential information.  Evaluation/re-training is conducted at regular intervals.

• Access to treatment records is limited to appropriate staff members in the office setting and in secure storage.  Records must be organized and retrievable to ensure availability to practitioners, office staff, Corphealth and the courts, if subpoenaed, or as required by law/statute.

• Practitioners assure that any request for records is legally permissible prior to making an associated disclosure.

• All requests for consultation and lab reports are documented.  Additionally, the review of reports from such requests is documented.

• Purging of treatment records is done according to state law.

For your reference, the treatment record documentation standards are located in the provider manual and on the Corphealth website at the link below.  Paper copies are available by contacting 866/279-7214.

Standards for Treatment Record Documentation