Joint Commission surveys of deemed status psychiatric hospitals include a session for B Tag Medical Record Reviews. In this session, surveyors review a sample of closed medical records to evaluate compliance with the CMS Special Medical Record Requirements for Psychiatric Hospitals.

This is in addition to the medical records reviewed during tracers for Joint Commission medical record documentation requirements. The focus of the B Tag review is quantitative (i.e. whether the required documentation is present or not). Psychiatric hospitals have become accustomed to this review, but there continue to be trouble spots that are consistently cited on surveys. These often result in a Condition level finding and a follow-up Medicare deficiency survey within 45 days.

Here’s some feedback from recent surveys on the “hot spots” that continue to challenge many hospitals.

Psychiatric Evaluations

Surveyors frequently cite psychiatric evaluations for lack of documentation on the mental status exam regarding intellectual functioning, memory functioning, orientation, insight, and judgment. The most common finding is that the mental status exam does not document how these elements were tested.

Psychosocial Assessments

Surveyors frequently cite psychosocial assessments for two particular shortcomings. One is not addressing “high-risk psychosocial issues requiring early treatment planning and intervention” – such as homelessness or non-compliance with medication. The other is not including in the treatment plan the “specific social work role in treatment and discharge planning.”

Treatment Plans

As in the past, surveyors continue to cite treatment plans for lack of measurable objectives, not being individualized (too “cookie cutter”), not including medical problems, and not being updated to address progress or lack of progress. Surveyors also frequently cite lack of documentation of alternative treatment when a patient does not attend scheduled groups. Remember, this must include not only what the alternative intervention was but also the patient’s response to that intervention.

Discharge Summaries

Surveyors commonly cite discharge summaries for lack of a complete summary of the patient’s course of treatment during the hospitalization. They also often cite that treatment of medical problems and information regarding Emergency Room visits are left out. Also, be aware that the discharge summary must specifically include the “patient’s psychiatric condition at discharge, physical condition at discharge, and functional condition at discharge.” Most hospitals routinely address psychiatric condition at discharge but often fail to address the other two elements.

Strategies for Compliance

So, what’s the best way to avoid these trouble spots? The organizations we’ve seen have the most success in these areas incorporate all of the following strategies for their medical records:

Medical Records Prompts

Whether it’s the mental status exam, the psychosocial assessment, the treatment plan, or the discharge summary, the first place to start (for both electronic medical records and paper records) is to build structured prompts into the documentation templates. These prompts should be based on the specific requirements of the B Tags to help clinicians word their findings in a way that meets the standard. (See our September 2017 newsletter article “Tips for Documenting the Mental Status Exam”  and our June 2016 article “Surveying Active Treatment in Psychiatric Hospitals.”)

B Tag Audits

There needs to be a robust B Tag audit process in place to review medical records for the CMS requirements. These audits should be done in a group setting with a team of consistent reviewers who have studied the B Tag requirements. It’s also critical for the group to work on inter-rater reliability so that all reviewers are evaluating compliance in a consistent manner. In addition, there needs to be real-time feedback to supervisors and staff so they can correct the problems. Lastly, aggregate data should be reviewed by leadership monthly so that compliance issues are addressed and don’t languish.

Accountability

While medical records documentation is not a favorite task of most clinicians, it’s a fact of life in a healthcare organization. Staff and licensed independent practitioners should be held accountable for their documentation meeting regulatory requirements. If there are problems with clinical documentation, it should be addressed in clinical supervision, through the performance evaluation process for staff, and through the Ongoing Professional Practice Evaluation (OPPE) process for LIPs.