Back

Treatment Records

Concordia is organizationally accountable for establishing and promulgating treatment record standards. Concordia requires treatment records to be maintained in a manner that is current, detailed, and organized which permits effective and confidential enrollee care and quality review.

Concordia has established treatment record documentation guidelines and standards for availability of treatment records, and performance goals to facilitate communication, coordination, and continuity of care within the behavioral health continuum, and among behavioral health clinicians, medical delivery systems, and primary care physicians.

The treatment record, whether electronic or on paper, communicates the enrollee’s clinical history; past and current health status; and treatment plans for future clinical care. Well-documented treatment records facilitate communication, coordination, and continuity of care as well as promote efficiency and effective treatment. Treatment records are the primary vehicle for the maintenance and communication of a patient’s personal health information. Consistent and complete treatment records are an essential component of quality patient care.

Treatment Record Keeping Standards

Concordia’s guidelines for treatment record documentation, standards for availability of treatment records, and performance goals define its expectations for practitioners. Concordia assesses treatment records to ensure that practitioners in its network comply with these guidelines and standards.

Treatment Record Review Guidelines

List of Record Review Guidelines

Treatment Review Results

Concordia reviews the treatment records of its high volume practitioners every year against its documentation standards. The documentation standards were adopted from twenty-four documentation guidelines proposed by the National Committee for Quality Assurance. Concordia’s performance goal is 85 percent for each criterion.

Back